Optum Rx Brochure

Transcription

Optum Rx Brochure

Welcome
OptumRx manages your pharmacy benefits for your benefit plan
sponsor. We look forward to serving you! Please take a few moments
to review this information to better understand your pharmacy
benefit plan.
Using Your ID Card
You can use your pharmacy benefit ID card at any pharmacy participating in your
plan’s pharmacy network. When you fill a prescription, the pharmacy enters your
claim in a computer system to automatically file it with OptumRx. Your pharmacy then
collects the copayment or coinsurance defined by your plan for each prescription you
purchase.
Your Plan’s Pharmacy Network
Your plan’s pharmacy network includes more than 64,000 independent and chain
retail pharmacies nationwide. To find a participating pharmacy near you, use the
pharmacy locator on our website at www.optumrx.com or call Customer Service
at 1-877-559-2955.
Using Non-network Pharmacies
If you present your ID card at a non-network pharmacy (or make a cash purchase
for other reasons), you will pay 100 percent of the retail cash price for your
prescription. To be reimbursed for eligible prescriptions, you must submit your
pharmacy receipt(s) and a pharmacy claim reimbursement form to OptumRx.
Reimbursement amounts are based on contracted pharmacy rates minus your
copayment or coinsurance. Please visit our website at www.optumrx.com,
contact your plan sponsor’s benefit manager or call Customer Service to get a
reimbursement form.
Welcome
Mail Service Pharmacy
Through OptumRx™ Mail Service Pharmacy, you could get up to a 90-day supply of
maintenance drugs — those you take regularly to treat ongoing health conditions —
delivered right to your home. Choose from one of two options to get started with mail
service in just one easy phone call:
• Option 1: Call OptumRx at 1-877-559-2955 (TTY 711).
• Option 2: Talk to your doctor. Tell your doctor you want to use OptumRx for home
delivery of your maintenance drugs. Be sure to ask for a new prescription written
for up to a 90-day supply with three refills to maximize your plan benefits. Then you
can either complete an order form and send it, along with your prescriptions and
copayment, to us or ask your doctor to call 1-877-559-2955 with your prescriptions
or to fax them to 1-800-491-7997.
Copayments/Coinsurance (Three-Tier)
Your plan sponsor has chosen a three-tier copayment and/or coinsurance structure.
A copayment or coinsurance is the portion of a drug’s price that you pay for out-ofpocket when you fill a prescription. Coverage for each copayment/coinsurance tier is
as follows:
Tier 1 (Preferred Generic Copayment/Coinsurance)
All eligible generic drugs.
Tier 2 (Preferred Brand Copayment/Coinsurance)
All eligible brand drugs preferred by your plan. To determine if you use a preferred
brand, please refer to your plan’s Preferred Products List (PPL). If the PPL is not included
with this letter, you may ask for a copy by calling customer service at 1-877-559-2955
or by visiting our website at www.optumrx.com.
Tier 3 (Nonpreferred Brand Copayment/Coinsurance)
All eligible brand drugs considered nonpreferred by your plan.
OptumRx | www.optumrx.com
Brands for Generic Program
Your plan’s Brands for Generic Program offers you a selection of brand name
products at your generic, or tier-1, copayment or coinsurance amount. Diabetic
members can also get select blood glucose meters at no charge1. If a brochure about
your plan’s Brands for Generic program is not included, please visit our website at
www.optumrx.com or call customer service at 1-877-559-2955 for more information.
Customer Service Center
Our team of dedicated Customer Service Advocates, many of whom are certified
pharmacy technicians, can assist you with all of your pharmacy benefit questions.
The Customer Service Center is available 24 hours a day, 7 days a week. Call us
toll-free at 1-877-559-2955.
No purchase necessary. Limit one free meter per person. Shipping costs may apply if you do not have Medicare. Meter offer
void where prohibited by state law.
1
www.optumrx.com
2300 Main Street, Irvine, CA 92614
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health
products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks
or registered marks of their respective owners.
ORX4275-INV_120714 ©2012 OptumRx, Inc.
FAQ: Using Your Pharmacy Benefits
Your pharmacy benefits help you get the right medication at a
reasonable price. Take a few minutes to better understand the features
and programs in your pharmacy plan. It can help you to get the most
from your benefits when making medication decisions with your doctor.
Who is OptumRx?
OptumRx is your plan’s pharmacy benefit manager (PBM). Your plan sponsor chose
us to manage and process your pharmacy claims. We will also answer your pharmacy
benefit questions and tell you about programs offered in your plan.
How do I find a participating retail pharmacy?
Your plan’s pharmacy network includes tens of thousands of chain and independent
pharmacies nationwide. To find one near you, visit our website, www.optumrx.com.
Then use the Locate a Pharmacy tool. Or call the customer service number on the
back of your member ID card.
How do I fill a prescription at a pharmacy?
There are several ways to fill/refill prescriptions
at your pharmacy:
• Option 1: Your doctor can call or fax your
new prescription or refill request
to the pharmacy.
• Option 2: Y
our pharmacist can call your doctor
to ask for a new prescription.
• Option 3: Visit your retail pharmacy to
request a refill or give them a new
prescription written by your doctor.
Why should I show my member ID card
when I fill a prescription?
Your pharmacy uses information on your ID card
to send your prescription claim to OptumRx to
process. Showing your ID card also ensures that
you pay the lowest possible cost.
Even when using a low-cost generics program,
such as those at Walmart, Costco and Target,
you should show your ID card. If the generic
drug costs less than your copayment or
coinsurance, you pay the smaller amount.
If your plan has a deductible, showing your
ID card allows your cost to go toward meeting
the deductible.
Can I order medications through the
Mail Service Pharmacy?
If your plan includes mail service, you can get up to
a 90-day supply of your maintenance medication(s)
from OptumRx™ Mail Service Pharmacy.
One easy phone call gets you started:
• Option 1: Call Customer Service —
They’ll help you start using the Mail Service
Pharmacy. Call the customer service number on
the back of your member ID card, 24 hours a
day, 7 days a week.
• Option 2: Talk to your doctor —
Tell your doctor you want to use OptumRx for
home delivery of your maintenance medications.
Be sure to ask for a new prescription for up to
a 90-day supply with three refills. Then mail
OptumRx your written prescription with a
completed order form. Or ask your doctor to
call 1-800-791-7658 with your prescription,
or fax it to 1-800-491-7997.
How long does it take to get my order
from the Mail Service Pharmacy?
Refills should arrive in about seven business days
after OptumRx receives your order. New orders
should arrive in about 10 business days. There is
no cost to you for standard delivery. Overnight
delivery is available for an additional charge.
How do I order refills from the
Mail Service Pharmacy?
When can I refill my prescriptions?
You have four ways to order refills from
OptumRx Mail Service Pharmacy:
You can usually refill prescriptions after you use
about two-thirds of the medication. For example,
when taken as prescribed:
• Order online at www.optumrx.com
• 30-day prescriptions may be refilled after 21 days
• Call our automated phone system
• 90-day prescriptions may be refilled after 63 days
• Call customer service at the number
on the back of your member ID card
• Complete the reorder form inside each
medication shipment and send it to us
for processing
Remember, by registering at our website, you’ll
receive email reminders when it is time to refill
your prescriptions.
Are generic drugs as good and safe
as brand-name drugs?
Yes. Every generic drug is equivalent to the
brand-name drug. They both have the same
strength, purity and quality. Both brand-name
and generic drugs meet U.S. Food and Drug
Administration (FDA) standards for safety
and effectiveness.
Can I get permission to refill my
medication early, such as before
I go on vacation?
If your plan allows early refills in special cases, call
customer service at the number on your member
ID card. Ask for an early refill authorization.
How do I request a prior authorization?
Certain medications may require special approval
from your plan to be covered. This is called prior
authorization. If your doctor prescribes one of
these medications, you, your pharmacist or doctor
can begin the review process by calling customer
service. A customer service advocate will work with
your doctor’s office to get the information for a
prior authorization review.
www.optumrx.com
ORX0415_121001 ©2012 OptumRx, Inc.
Brands for Generic Program
Through our Brands for Generic Program, OptumRx helps make
diabetic testing supplies and insulin products more affordable.
The program gives you access to our buying power for major
discounts on select brand name diabetes products.
Significant Savings on Brand Medications
Using the Brands for Generic Program is easy. Simply get a prescription for a
product listed in the chart below and take it to a participating pharmacy. When
the pharmacy fills your prescription, they will submit your claim for coverage
by your benefit plan. They will then collect your applicable generic or first-tier
copayment amount.
To qualify for the Brands for Generics Program, a brand medication must
be dispensed.
Category and Manufacturer
Brand Product
Diabetic supplies*
by Roche Diagnostics
ACCU-CHEK® Aviva test strips
ACCU-CHEK® Aviva Plus test strips
ACCU-CHEK® Compact test strips
ACCU-CHEK® Comfort Curve test strips
ACCU-CHEK® Active test strips
ACCU-CHEK® SmartView
OneTouch® Basic Test Strips
OneTouch® Profile Test Strips
OneTouch® SureStep Test Strips
OneTouch® Ultra Test Strips
OneTouch® Verio Test Strips
Precision brand syringes
Diabetic supplies**
by Lifescan Inc., a Johnson &
Johnson company
Diabetic supplies*
by Abbott MediSense
Injectable hypoglycemic agents
by Lilly
Injectable hypoglycemic agents
by Novo Nordisk
Humulin (vial only; not Conc.)
Humalog (vial only)
Novolin (vial only)
Novolog (vial only)
T he products offered in this program are subject to change without notice. Product list does not imply coverage,
see plan information for specific benefit and coverage limitations.
* Roche Diagnostics ACCU-CHEK®, Lifescan and OneTouch® blood glucose meters are available at no charge to
members of pharmacy benefit plans administered by OptumRx when the members’ plan design includes the Free
Meter Program. Contact the customer service center for details.
About Insulin and Blood Sugar Testing
Effectively managing diabetes can lower the risk of diabetic complications, which
include nerve, eye, kidney and blood vessel damage. Regular blood sugar testing and
insulin therapy are often part of a diabetes care plan. The results of testing tell if a care
plan is working and insulin can help maintain healthy blood sugar levels.
www.optumrx.com
Prior Authorization
Some medications must be authorized for coverage because they’re only
approved or effective in treating specific illnesses, they cost more or they may
be prescribed for conditions for which safety and effectiveness have not been
well‑established.
Reviewing Medications
Our review committee of independent doctors and pharmacists meets regularly
to review medications and consider how they should be covered by pharmacy
benefit plans. They also recommend prior authorization guidelines.
Safe and Effective
When making recommendations, the review committee focuses on proven
medication safety, effectiveness and cost. The committee considers:
• U.S. Food and Drug Administration (FDA) approved indications
• Manufacturer’s package labeling instructions
• Well-accepted and/or published clinical recommendations
Getting a Short-Term Supply
If you must start taking a medication that requires prior authorization right
away, two options may be available to you. First, ask your doctor if a sample is
available. If not, check with your pharmacy to request a short-term supply of five
days or less — keep in mind you will be responsible for the full cost at that time.
If the prior authorization request is approved, then your pharmacist can dispense
the rest of your prescription.
Requesting a Prior Authorization
You, your pharmacist or your doctor can start the prior authorization review
process by contacting our prior authorization department. A pharmacy
technician then works with your doctor to get the information needed for the
review. Once we receive a completed prior authorization form from your doctor,
we conduct a clinical review within two business days. We then send you and
your doctor a letter regarding the prior authorization decision.
Prior Authorization
Prior Authorization List
Products on these pages may require prior authorization as determined by your specific
benefit plan design. For more information, contact customer service at the number on
the back of your benefit plan ID card.
Acne
Accutane, Amnesteem, Claravis, Sotret
ADHD
Daytrana, Focalin XR, Intuniv, Kapvay, Metadate CD, Methylin Chew, Procentra Sol, Ritalin LA
10 mg, Strattera
Androgenic AgentsAndroderm, Androgel, Android, Axiron,
Delatestryl, Depo-Testosterone, Fortesta,
Methitest, Striant, Testim, testosterone
cypionate, testosterone enanthate, Testred
Antiarrhythmics Multaq
Antibiotic
Dificid, Ketek, Zyvox
Anticoagulant
Pradaxa, Xarelto
Anticonvulsant
Onfi, Sabril
AntidepressantViibryd
Antidiabetic Agents Cycloset
AntidotesFerriprox
AntiemeticCesamet, dronabinol, Emend, Marinol
Antifungal
itraconazole, Onmel, Sporanox
Antimalarial AgentsQualaquin
Antipsychotic
Fanapt/Fanapt Pak, Geodon, Invega, Latuda
Antiviral
Copegus, Rebetol, Ribapak, ribavirin
Antiviral Monoclonal AntibodiesSynagis
Anti-cataplexyXyrem
AsthmaXolair
Cancer/LymphomaAbraxane, Afinitor, Alimta, Arzerra, Avastin,
Bosulif, Campath, Caprelsa, Eligard, Erbitux,
Erivedge, Femara, Folotyn, Gleevec, Halaven,
Herceptin, Inlyta, Intron-A, Iressa, Istodax, Jakafi,
Jevtana, Kyprolis, Nexavar, Novantrone, Ontak,
Perjeta, Proleukin, Revlimid, Rituxan, Sprycel,
Stivarga, Sutent, Sylatron, Synribo, Tarceva,
Targretin, Tasigna, Thalomid, Torisel, Treanda,
Trisenox, Tykerb, Vandetanib, Vectibix, Velcade,
Votrient, Xalkori, Xgeva, Xtandi, Zaltrap,
Zelboraf, Zolinza
Chemotherapy Protective Agent
dexrazoxane, Totect, Zinecard
Cholesterol Lowering
simvastatin 80 mg, Vytorin 10-80 mg,
Zocor 80 mg
CNS Stimulant
Nuvigil, Provigil
COPD
Arcapta Neohaler, Daliresp
Cryopyrin-associated
Periodic Syndromes
Arcalyst, llaris
Dermatological Agents Picato
Endocrine/Metabolic Agents
Kalydeco, Korlym
Enzyme Replacement TherapyAldurazyme, Elaprase, Fabrazyme, Lumizyme,
Myozyme, VPRIV
Gaucher DiseaseZavesca
Growth HormoneGenotropin, Humatrope, Norditropin,
Nutropin/AQ, Omnitrope, Saizen, Serostim,
Tev-Tropin, Zorbtiv
Growth HormoneSomavert
Receptor Antagonist
Growth Hormone Releasing Factor (GRF) Analog
Egrifta
Hematological AgentsSoliris
Hematopoietic Growth FactorsAranesp, Epogen, Leukine, Neulasta, Neumega,
Neupogen, Nplate, Omontys, Procrit, Promacta
Hepatitis CIncivek, Infergen, Pegasys, PEG-Intron, Victrelis
Hereditary AngioedemaBerinert, Cinryze, Firazyr, Kalbitor
Hormones - Miscellaneous
Makena, methyltestosterone/estrogen
Huntington’s DiseaseXenazine
Hypnotics
chloral hydrate, flurazepam, Somnote
ImmuneglobulinsCarimune Nanofiltered, Flebogamma,
Gamastan S/D, Gammaked, Gammagard Liquid,
Gammagard S/D, Gamunex, Hizentra, Octagam,
Privigen, Vivaglobulin
ImmunosuppressantZortress
Immunosuppressant - topical
Elidel, Protopic
Insulin-like Growth FactorIncrelex
Irritable Bowel Syndrome
Linzess, Lotronex
Multiple SclerosisAmpyra, Aubagio, Avonex, Betaseron,
Copaxone, Extavia, Gilenya, Rebif, Tysabri
Narcotic Analgesic bstral, Actiq (fentanyl oral transmucosal),
A
Butrans, Fentora, Lazanda, Onsolis, Subutex,
Suboxone/SL
Neuromuscular Blocking Agent
Botox, Dysport, Myobloc, Xeomin
Non-narcotic Analesic
Conzip
NSAIDCelebrex, Vimovo (electronic step edit)
Opioid-Induced ConstipationRelistor
OsteoporosisForteo, Prolia, Reclast
Paget’s DiseaseReclast
Parkinson’s DiseaseApokyn
Plaque Psoriasis8-MOP, Amevive, Stelara, Oxoralen Ultra
Pseudobulbar AffectNuedexta
(PBA) Agents
Pulmonary Hypertension AgentsAdcirca, Letairis, Revatio, Tracleer, Tyvaso,
Veletri, Ventavis
Respiratory Agents Glassia
Rheumatoid ArthritisActemra, Kineret, Orencia, Xeljanz
Somatostatic Agents
octreotide, Sandostatin, Somatuline
Stem Cell MobilizerMozobil
TNF AntagonistCimzia, Enbrel, Humira, Remicade, Simponi
Vasopressin V2-receptorSamsca
Antagonist
ViscosupplementsEuflexxa, Hyalgan, Orthovisc, Supartz, Synivsc,
Synvisc One
Wound CareRegranex
www.optumrx.com
Quantity Limits on Medications
Your pharmacy benefit plan’s quantity limits program protects
you and can help you get the best results from your medication
therapy. Along with supporting safe and appropriate dosing,
quantity limits can also keep prescription drug costs lower for
you and your benefit plan sponsor.
Determining Quantity Limits
Quantity limits are meant to minimize the risk of over-dosing and unwanted
drug interactions. Quantity limit rules are based on:
• Food and Drug Administration (FDA) approved indications
• Manufacturer’s package labeling instructions
• Well-accepted or published clinical recommendations
Establishing Guidelines for Use
Our review committee of independent doctors and pharmacists meets regularly
to review medications and consider how they should be covered by pharmacy
benefit plans. They also recommend quantity limit guidelines.
List of Medications with Quantity Limit
MEDICATION NAME
THERAPY CLASS
LIMIT
Acanya
Actiq (fentanyl oral transmucosal)
Actonel 35 mg
Actonel 75 mg
Actonel 150 mg
Acular
Acular LS
Acuvail
Adoxa (doxycycline monohydrate)
100 mg, 150 mg
Adoxa (doxycycline monohydrate)
50 mg, 75 mg
Adoxa CK kit, TT kit
Adrenaclick
(epinephrine inj device)
Advair Diskus/HFA
Aerobid, Aerobid-M
Afinitor
Aldara
Dermatological — Acne
Narcotic analgesic
Osteoporosis
Osteoporosis
Osteoporosis
Ophthalmic NSAID
Ophthalmic NSAID
Ophthalmic NSAID
Antibiotic
120 units per month (4 per day)
1 kit per month
4 tablets per 28 days
1 tablet per 30 days
15 mL per month
5 mL per month
65 units per 180 days
30 tablets per prescription
Antibiotic
20 tables per prescription
Antibiotic
Anaphylactic Emergency
1 Kit per prescription
2 devices per prescription
Asthma/COPD
Asthma/COPD
Cancer
Dermatological — Misc.
Alocril
Alomide
Alora
Alphagan P
Alrex
Altabax
Alvesco
Amerge (naratriptan)
Androderm 2.5 mg
Androderm 2 mg 4 mg and 5 mg
Androgel 1% (50 mg)
Androgel 1% (25 mg)
Androgel Pump 1.62%
Ophthalmic antiallergic
Hormone replacement therapy
Ophthalmic — Misc.
Ophthalmic steroid
Antibiotics — Topical
Asthma/COPD
Acute migraine therapy
Androgenic Agents
Androgenic Agents
Androgenic Agents
Androgenic Agents
Androgenic Agents
Anzemet 50 mg
Amzemet 100 mg
Aranesp
Nausea and vomiting
Nausea and vomiting
Hematopoietic agent
1 device per month
3 devices per month
1 month supply per disensing
36 packets per 112 days
(one copay per 12 packets)
3 (5 ml) bottles per month
8 patches per 28 days
10 mL per month
1 tube per month
2 devices per month
18 tablets per month
60 patches (1 box) per month
30 patches (1 box) per month
300 gm per month
30 packets per month
150 gm (2 pump bottles)
per month
6 tablets per Rx
3 tablets per Rx
28 day supply per dispense
Page
Abstral title interior spread
Narcotic analgesic
2 OptumRx | www.optumrx.com
MEDICATION NAME
THERAPY CLASS
LIMIT
Asmanex 110 mcg
Asmanex 220 mcg
Astelin
Astepro
Atelvia
Avinza 120 mg
Avinza 30 mg, 45 mg,
60 mg, 75 mg, 90 mg
Avonex
Axert
Axiron
Azasite
Azmacort
Beconase AQ
Benzaclin (clindamycin / BP gel)
Benzaciln with pump
Bepreve
Besivance
Betaseron
Binosto
Blood glucose testing strips
(all brands and generics)
Boniva 150mg
Brevoxyl-8 Creamy Wash Kit
Brimonidine sol.
Bromday
Butrans
Bydureon
Byetta
Cambia
Caprelsa (vandetanib)
Catapres-TTS -1
(clonidine TD patch-1)
Catapres-TTS -2, -3
(clonidine TD patch -2, -3)
Cesamet
Cialis 2.5 mg, 5 mg
Cialis 10 mg, 20 mg
Ciclodan Kit
Asthma/COPD
Asthma/COPD
Allergy — Intranasal
Osteoporosis
Narcotic analgesic
Narcotic analgesic
1 device per month
1 device per month
2 (30 ml) devices per month
2 (30 ml) devices per month
60 capsules per month (2 per day)
Multiple sclerosis
Androgenic Agents
Ophthalmic antibiotic
Asthma/COPD
Acne
Acne
Ophthalmic antihistamine
Multiple Sclerosis
Osteoporosis
Diabetic testing supplies
4 injections per month
2 (90 mL) bottles per month
1 (2.5 ml) bottle per month
2 devices per month
2 (25 gm) devices per month
50 gm per month
50 gm per month
1 (10 mL) bottle per month
5 mL per month
4 tabs per 30 days
150 test strips per month
Osteoporosis
Acne
Ophthalmic-misc
Ophtlamic antiallergic
Narcotic analgesic
Diabetes
Diabetes
Acute Migraine Therapy
Cancer
Blood Pressure
1 tablet per 30 days
1 Kit per month
10 mL per month
1 bottle (1.7 mL) per month
1 box (4 patches) per 28 days
4 vials per month
1 pen (60 doses) per month
9 packets per month
1 month supply per dispensing
5 patches per month
Blood Pressure
10 patches per month
Nausea and vomiting
Sexual dysfunction
Sexual dysfunction
Dermatological-Misc.
20 capsules per copay
6 tablets per month
544 grams per prescription
3
MEDICATION NAME
THERAPY CLASS
LIMIT
Ciloxan Ophthalmic Ointment
Ciloxan Ophthalmic Solution
Cimzia
Cimzia Starter Kit
Ciprofloxacin Ophthalmic Solution
Climara
Climara Pro
Combigan
Combipatch
Copaxone
Cordran
Cordran SP
Cordran Tape
Diastat (diazepam rectal gel)
Desonil Plus Kit
(cream and ointment)
Diclofenac Ophthalmic Solution
Differin (adapalene) cream
Differin Lotion
Differin (adapalene) gel
Diflucan (fluconazole) 150 mg
Doryx 100 mg
Doryx 75 mg
Duac CS
Dulera
Duragesic (fentanyl TD)
12.5 mcg, 25 mcg, 50 mcg
Duragesic (fentanyl TD)
75 mcg, 100 mcg
Dymista
TNF Antagonist
TNF Antagonist
Glaucoma
Multiple Sclerosis
Topical corsticosteroid
Seizure disorder
7 gm per month
10 mL per month
2 doses per 28 days
1 kit per 365 days
10 mL per month
10 mL per month
60 mL per month
60 gm per month
1 box per month
2 boxes per prescription
1 kit (130 gm) per month
Ophthalmic — NSAIDS
Acne
Acne
Acne
Antifungal
Antibiotic
Antibiotic
Acne
Asthma/COPD
Narcotic analgesic
7.5 mL per month
1 tube (45 gm) per month
1 bottle (59 mL) per month
1 tablet per copay
1 kit per 30 days
1 device per month
Narcotic analgesic
Allergy-Intranasal
1 bottle per month
Egrifta
Growth Hormone Releasing
Factor (GRF)
Immunosuppressive
Agent — Topical
Emergency contraceptive
Narcotic analgesic
30 vials (1 box) per month
Elestat
Elidel
Ella
Embeda
2 (5 ml) bottles per 30 days
100 gm (1 tube) per month
1 tablet per prescription
MEDICATION NAME
THERAPY CLASS
LIMIT
Emend (combo pack)
125 mg - 80 mg
Emend 40 mg & 125 mg
Emend 80 mg
Enbrel 25mg
Enbrel 50 mg
Epiduo
EpiPen, EpiPen Jr
Epogen
Estraderm
Estradiol TD patch weekly
Estrasorb
Estrogel
Evoclin
(clindamycin phosphate foam)
Estring
Exalgo
Extavia
Femring
Fentora
Flovent Diskus 250 mcg
Flovent Diskus
50 mcg, 100 mcg
Flovent HFA
Flurbiprofen Ophthalmic Solution
Foradil
Forteo
Fortesta
Fortical (calcitonin) nasal spray
Fosamax 35 mg, 70 mg
Fosamax D 70/2800, 70/5600
Fosamax Oral Solution
Frova
Fuzeon
Gelnique Gel
Nausea and vomiting
1 pack per dispensing
Nausea and vomiting
Nausea and vomiting
TNF Antagonist
TNF Antagonist
Acne
Hematopoietic agent
1 capsule per dispensing
2 capsules per dispensing
8 doses per 28 days
4 doses per 28 days
45 gm per month
2 Devices per prescription
56 packets per 28 days
1 bottle (93 gm) per month
50 gm per month
Narcotic analgesic
Multiple Sclerosis
Narcotic analgesic
Asthma/COPD
Asthma/COPD
1 device per 3 months (3 copays)
6 tablets per day
1 device per 3 months (3 copays)
240 blisters per month
Asthma/COPD
Asthma/COPD
Osteoporosis
Androgenic Agents
Osteoporosis
Osteoporosis
Osteoporosis
Osteoporosis
HIV antiviral
Genitourinary
Gelnique Gel 3%
Genitourinary
2 devices per month
2.5 mL per month
60 capsules per month
24 months of therapy
2 (60 gm) bottles per month
3.8 ml per month
375ml per month
1 kit per 30 days
30 sachets per month
(1 sachet daily)
1 bottle per 30 days
5
MEDICATION NAME
THERAPY CLASS
LIMIT
Gleevec
Golytely (PEG 3350 electrolyte sol)
Gralise Starter Kit
Granisol oral sol.
Helidac
Humira
Humira Crohn’s Disease Starter Kit
Humira Psoriasis Starter Kit
Imitrex (sumatriptan)
25 mg, 50 mg, 100 mg
Imitrex (sumatriptan) Injections
Imitrex (sumatriptan) Nasal Spray
Iquix
Iressa
Jolessa
Kadian
Ketek
ketorolac 10 mg
Kineret
Kytril (granisetron)
Cancer
Laxatives
Diabetic Peripheral Neuropathy
Nausea and vomiting
Ulcer therapy
TNF Antagonist
TNF Antagonist
TNF Antagonist
4000 mL per prescription
1 kit per prescription
30 mL per 3 days
1 kit per 6 months
1 package (2 doses) per 28 days
1 kit per year
1 kit per year
Cancer
Oral contraceptive
Narcotic analgesic
Antibiotics
Analgesics and narcotics
Rheumatoid arthritis
Nausea and vomiting
Lamictal/ODT/XR Starter Kit
Lastacaft
Lazanda
Levitra
Lidoderm
Anticonvulsants
Ophthalmic Antihistamine
Narcotic Analgesic
Sexual dysfunction
Anesthetic patch
Livostin
Lo-Seasonique
Lotemax
Lumigan
Lupron Depot 11.25, 22.5
Luveris
Lysteda
Maxalt and Maxalt MLT
Menostar
Mesalamine Kit
Oral contraceptive
Ophthalmic steroids
Glaucoma
Cancer
Infertility
Hermostatic Agent
Osteoporosis
Gastrointestinal — Misc.
4 kits per month
12 devices (2 packages) per month
15 mL per month
1 package per 91 days (3 copays)
20 dosage units per 30 days
1 kit per 28 days
6 tabs per prescription or 3 day
supply (which ever is least)
1 box per prescription
1 (3 mL) bottle per month
30 bottles per month (1 per day)
6 tablets per month
3 boxes (90 patches) per month or
3 patches per day
15 mL per month
1 unit per 90 days
14 vials per copay
1 kit per 7 days
MEDICATION NAME
THERAPY CLASS
LIMIT
Metoclopramide
Metozolv ODT
Miacalcin (calcitonin) nasal spray
Migranal
Minivelle
Monodox (doxycycline) 75 mg cap
Morgidox Kit
Moxeza
MS contin (morphine sulfate ER)
15 mg, 30 mg, 60 mg, 100 mg
MS contin (morphine sulfate ER)
200 mg
Namenda Titration Pak
Nasacort AQ (triamcinolone
acetonide nasal inhaler)
Nasonex
Natacyn
Neulasta
Neupogen
Nevanac
Nexavar
Nucynta 50 mg, 75 mg
Nucynta 100 mg
Nulytely
Ocudox Kit
Ocufen (flurbiprofen)
Ocuflox
Ofloxacin Ophthalmic Drops
Omnaris
Onsolis
Opana (oxymorphone)
Opana ER
Optivar
Oramorph SR
Oravig
Orencia 125 mg
Gasteointestinal — Misc.
Osteoporosis
Hormone Replacement Therapy
Antibiotic
Antibiotic
Narcotic analgesic
12 weeks of therapy per 6 months
3.8 ml per month
8 units (1 kit) per month
20 capsules per prescription
1 kit per month
1 (3 mL) bottle per prescription
120 tablets per month (4 per day)
Narcotic analgesic
Alzheimers Agent
1 kit per month
1 (16.5 gm) device per month
Hematopoietic agent
Hematopoietic agent
Ophthalmic NSAID
Cancer
Narcotic analgesic
Narcotic analgesic
Gastrointestinal - misc.
Antibiotic
Ophthalmic NSAID
Narcotic analgesic
Narcotic analgesic
Narcotic analgesic
Narcotic analgesic
Antifungal
TNF Antagonist
2 (17 gm) devices per month
1 (15 ml) bottle per 15 days
6 mL per month
4000 mL pre prescription
1 kit per prescription
2.5 mL per month
10 mL per month
10 mL per month
1 device (12.5 gm) per month
14 tablets per dispensing
4 ml (4 syringes) per month
7
MEDICATION NAME
THERAPY CLASS
LIMIT
Oxycontin
Oxytrol
Pataday
Patanase
Patanol
Plan B One-Step
Prevacid NapraPAC
Narcotic analgesic
Genitourinary
Emergency contraceptive
Analgesic/anti-ulcer
combination
H. pylori
Asthma/COPD
Hematopoietic agent
Immunosuppressive
Agent — Topical
Asthma/COPD
SSRI antidepressant
Asthma/COPD
H. pylori
Allergy-Intranasal
Asthma/COPD
Asthma/COPD
Multiple Sclerosis
Multiple Sclerosis
Wound care
Wound care
Influenza antiviral
Ophthalmic-other
Cancer
Acne
Acne
Acne
Acne
2 (2.5 ml) bottles per 30 days
1 tablet per prescription
1 box (84 units) per month
Prevpac
ProAir HFA
Procrit
Protopic
Proventil HFA
Prozac Weekly
Pulmicort
Pylera
Qnasl
Quixin
QVAR 40 mcg
QVAR 80 mcg
Rebif
Rebif Titration Pack
Regenecare Wound Gel
Reglan
Regranex
Relenza
Relpax
Restasis
Retin-A Micro
Revlimid
Rhinocort Aqua
Rosula aerosol, foam
Rosula Cleanser
Rosula CLK Kit
Rosula Gel 10-5%
14 daily dose cards per 6 months
2 devices per month
100 gm (1 tube) per month
2 devices per month
2 devices per month
120 tablets per 6 months
1 device per month
10 mL per month
2 devices per month
3 devices per month
12 injections per 28 days
1 titration pack per year
1 copay per package
2 (15 gm) tubes per month
2 per day
50 gm per month
2 (8.6 gm) devices per month
1 can (100 gm) per month
1 Kit per month
MEDICATION NAME
THERAPY CLASS
LIMIT
Rosula NS
Rosula Wash
Rowasa Kit
Sancuso
Savella Titration Pack
Seasonale
Seasonique
Serevent Diskus
Serostim
Simponi
Solaraze
Acne
Acne
Nausea and vomiting
Fibromyalgia
Contraception
Oral contraceptive
Asthma/COPD
HIV wasting
TNF Antagonist
Dermatological —
Actinic Keratoses
Psoriasis
Psoriasis
Asthma/COPD
NSAIDS
Cancer
Narcotic analgesic nasal spray
Narcotic antagonist
Narcotic
Narcotic analgesic
Narcotic antagonist
Narcotic antagonist
Acute Migraine Thearpy
Laxatives
2 boxes (60 pads) per month
1 kit per 7 days
1 patch per copay
1 pack per prescription
1 device per month
30 vials per month
1 dose per month
100 gm per month
Soriatane Kit 10 mg
Soriatane Kit 25 mg
Spiriva
Sprix Spray
Sprycel
Stadol NS (butorphanol)
Suboxone
Suboxone SL Film
Subsys
Subutex 2 mg
Subutex 8 mg
Sumavel DosePro
Suprep Bowel Sol.
Sutent
Symbicort
Taclonex Oint
Taclonex Susp
Tamiflu 30 mg
Tamiflu 45 mg, 75 mg
Tamiflu Oral Suspension
6 mg/mL
Tamiflu Oral Suspension
12 mg/mL
Cancer
Asthma/COPD
Dermatological Agents - Misc
Influenza antiviral
Influenza antiviral
Influenza antiviral
1 kit per month
2 kits per month
5 doses (5 bottles) per month
3 (2.5 ml) pumps per month
93 films per month (3 per day)
12 unit doses per day
8 tablets per month
8 units per month
354 mL (2 bottles)
per prescription
1 device per month
60 grams per 30 days
150 mL per month
Influenza antiviral
75 mL per month
9
MEDICATION NAME
THERAPY CLASS
LIMIT
Tarceva
Tasigna
Tazorac Cream
Tazorac Gel
Terazol 3 Supp
Cancer
Cancer
Vaginal antifungal
Terazol 7
Testim
Thalomid
Tobradex ST
Tobrex (tobramycin)
Travatan/Z
Treximet
Triaz cloths (BPO cloths)
Tudorza Pressair
Twinject
Tykerb
Tyzeka
Vandetanib
Veltin Gel
Ventolin HFA
Veramyst
Veregen
Viagra
Victoza
Vigamox
Viibryd Kit
Viroptic (trifluridine)
Vivelle
Vivelle-Dot
Voltaren (diclofenec)
ophthalmic solution
Votrient
Xalatan
Xalkori
Xibrom (bromfenac op sol)
Vaginal antifungal
Androgenic Agents
Cancer
Glaucoma
Acne
COPD
Cancer
Hepatitis
Cancer
Acne
Asthma/COPD
External genital warts
Sexual dysfunction
Diabetes
Antidepressant
Ophthalmic antiviral
Ophthalmic NSAID
1 kit (3 suppositories)
per prescription
1 tube (45 gm) per prescription
300 gm per month
20 mL per prescription
5 mL or gm per prescription
9 tablets per month
1 box (60 units) per 30 days
1 device per 30 days
2 devices per prescription
2 devices per month
1 (10 gm) device per month
16 weeks of therapy per year
6 tablets per month
3 pens per month
3 mL per prescription dispensing
30 tablets (1 kit) per prescription
1 (7.5 ml) bottle per 15 days
7.5 mL per month
Cancer
Glaucoma
Cancer/Lymphoma
2.5 mL per month
MEDICATION NAME
THERAPY CLASS
LIMIT
Xopenex HFA
Xyrem
Zelboraf
Zetonna
Ziana
Zirgan
Zofran (ondansetron)
2 mg, 4 mg, 24 mg
Zofran (ondansetron) 8 mg
Zofran (ondansetron) ODT
2 mg, 4 mg
Zofran (ondansetron) ODT 8 mg
Zofran (ondansetron) oral solution
Zolinza
Zolpimist Spray
Zomig and Zomig ZMT 2.5 mg
Zomig and Zomig ZMT 5 mg
Zomig Nasal Spray
Zorbtive
Zuplenz 4 mg
Zuplenz 8 mg
Zyclara
Zyclara Pump
Zymar
Zymaxid
Zioptan
Asthma/COPD
Narcolepsy/Cataplexy
Cancer/Lymphoma
Allergy-Intranasal
Acne
Ophthalmic antinfective
Nausea and vomiting
2 devices per month
540 mL per month
1 inhaler per month
60 gm per month
5 gm per month
Nausea and vomiting
Nausea and vomiting
Nausea and vomiting
Nausea and vomiting
Cancer
Sedative Hypnotics
Short Bowel Syndrome
Nausea and vomiting
Nausea and vomiting
Glaucoma
600 mL per month
1 (7.7 mL) bottle per month
9 tablets per month
12 units per month
30 vials per month
18 films per month
60 films per month
2 boxes (56 units) per 60 days
15 gm per 45 days
5 mL per month
1 (2.5 mL) bottle per month
30 containers (9 ml) per 30 days
11
This is only a partial listing and not all products may be covered by your
pharmacy benefit plan. Your specific benefit plan’s guidelines regarding quantity
limits will apply. Call customer service at the member phone number on the back
of your ID card for more information.
www.optumrx.com
Retail Pharmacies and Retail 90 Rx
A well-balanced pharmacy network offers you convenient access
and competitive discounts for brand and generic medications. Our
national retail pharmacy network includes more than 60,000 chain
and independent retail pharmacies, so you’re sure to find one close
to home or work.
Using Your ID Card
When you fill a prescription through a participating pharmacy, show the pharmacy
your ID card so they can submit a claim for coverage by your pharmacy benefit plan.
When you pick up your prescription, the pharmacy then collects your applicable
member contribution as defined by your plan.
If you do not present your ID card or you fill a prescription at a non-participating
pharmacy, you pay the full retail price for your medication. If the prescription is eligible
for coverage under your pharmacy benefit plan, you may submit a claim to request
reimbursement (forms are available at www.optumrx or by calling customer service).
When you submit a claim using the reimbursement form, OptumRx first determines if
your plan covers the medication. If it is covered, the amount you receive is based on
contracted pharmacy rates less your plan’s out-of-pocket member contribution. All
prescription claims are subject to your pharmacy benefit plan’s rules and restrictions.
Retail Pharmacies and Retail 90 Rx
Retail 90 Rx Program
The Retail 90 Rx Program allows you to receive up to a three-month supply of your medication from
more than 59,000 participating retail pharmacies. Like a traditional mail service pharmacy, you can
avoid refilling a prescription every month while still getting personalized counsel from a local pharmacy
professional. See your benefit plan documents for Retail 90 Rx copayment information.
To use Retail 90 Rx, talk with your doctor to see if the program is right for you. If it is, get a prescription
written for up to a 90-day supply and take it to a participating Retail 90 Rx pharmacy. Please note, some
medications are limited by law and cannot be dispensed as a three-month supply. Not all medications are
eligible for this program.
Finding a Network Pharmacy
You can choose from three easy ways to find participating pharmacies near you:
1. R
eview the partial list included on the following pages.
2. G
o to our website and use the LOCATE A PHARMACY tool.
3. C
ontact customer service using the number on the back of your benefit plan member ID card.
A
90
Dahl’s Pharmacy
90
Brookshire Brothers
90
AADP
90
Brookshire Grocery
Department of Veterans Affairs
Pharmacies
Accredo Health
90
Buehler Foods
90
Dierbergs Pharmacy
Buehlers
90
Dillon’s Pharmacy (Kroger)
90
Discount Drug Mart
A&P Pharmacy
90
A S Medication Solutions
90
Acme Pharmacy
C
Ahold USA
AHS — St. John Pharmacy
90
Albertsons
Carle Rx Express
90
Allina Community Pharmacy
Carrs Quality Center
90
American Drug Stores
Central Dakota Pharmacies
90
Appalachian Regional Health
90
City Market (Kroger)
90
Apria Healthcare
90
Coborn’s Pharmacy
90
Arrow Prescription Center
90
Concord Food Stores
90
Aurora Pharmacy
90
90
Dominicks Pharmacy
Drug Fair Community
Drug World Pharmacies
90
Duane Reade
Duluth Clinic Pharmacies
E
Eaton Apothecary
Community Distributors
B
90
Doc’s Drugs Ltd
Care Pharmacies
90
90
D
Bioscrip Pharmacy
Brockie Healthcare
90
90
90
F
Continuing Care Rx
Balls Four B
90
Coram
90
Fagen Pharmacy
Bartell Drug
90
Costco Pharmacies
90
Fairview Health Services
Bi-Lo
Curascript Infusion Pharmacy
90
Familymeds
Bi-Lo Pharmacy
Curators of the University of Missouri
90
FF Acquisition
CVS/Pharmacy
90
Food Lion
Bimart
90
90
90
Fred Meyer (Kroger)
90
King Kullen Pharmacy
Neighborcare Pharmacy Services
Fred’s Pharmacy
90
King Soopers Pharmacy (Kroger)
New Albertsons
Freds Stores of Tennessee
90
Kinney Drugs
Northwest Health Ventures
Fruth Pharmacy
Klingensmith’s Drug Stores
Frys Food And Drug (Kroger)
Knight Drugs
G
Gemmel Pharmacy
90
Omnicare Inc.
Kohll’s Pharmacy & Homecare
90
Oncology Pharmacy Services
Kroger Pharmacy
90
Option Care
Genuardis Pharmacy
KS Management Services
90
Giant Eagle Pharmacy
K-VA-T Food Stores
90
Giant Food Stores
90
Giant Of Maryland
90
Gristedes Pharmacy
90
GRT Atlantic & Pacific Tea
90
H
Haggen Food & Pharmacy — WA
90
L
90
O
Levandowski
P
Pacmed Clinics
90
Pamida Stores
90
Park Nicollet Pharmacy
Lifechek
Parkway Drugs — IL
90
LML Enterprises
90
Longs Drug Stores — CA
Patient First
90
Louis and Clark Drug
Pavilion Plaza Pharmacy
90
Lovelace Health Systems
Hannaford Bros
M
Pathmark Stores
90
Penn Traffic
90
Perlmart/Shoprite
90
Harmons City
90
Harris Teeter Pharmacy
M.K. Stores
Hartig Drug
Marc Glassman
90
Pharmacy Express Services
Harvard Vanguard Medical Associates
Market Basket Pharmacies
90
Pharmerica
Marsh Drugs
90
Piggly Wiggly
Marshfield Clinic Pharmacy
90
Price Chopper Pharmacy
90
Health Partners
90
90
HEB Grocery
Henry Ford Health System
90
90
90
HIP Pharmacy Service of NY
Homeland Stores
90
90
Publix Super Markets
Q
Med-X Drug
Hy-Vee Food Stores
90
Medfusion Pharmacy
90
QFC (Kroger)
90
Medicap Pharmacies
90
Quality Markets Pharmacy
Medicine Centers of Atlanta
90
Quick Chek Pharmacy Dept
IHC Health Services
90
Inserra Supermarkets
90
Insty Meds
Medicine Shoppe
Mediserv
Meijer
Mercy Health System
Minyard Food Stores
JH Harvey
Moore and King Pharmacy
Jordan Drug
K Mart Pharmacy
90
Kash in Karry Food Stores
90
Kerr Drug Stores
R
90
Raley’s Pharmacy
90
Ralphs (Kroger)
90
Randalls
90
Rinderer’s Drug Stores
90
Rite Aid
Morton Drug
K
90
Professional Pharmacy Services
Mays Drug Stores
90
J
90
Procare Pharmacy
Horton and Converse Pharmacy
Ingles Markets Pharmacy
90
90
Med-Fast Pharmacy
I
90
90
Price Cutter Pharmacy
Martins Super Markets
Maxor Pharmacy
Hi-School Pharmacy
90
Pharma-Card
N
90
Nash Finch
Navarro Discount Pharmacy
90
Neighborcare Pharmacy of VA
Ritzman Pharmacy
90
Ronetco
Rxd Pharmacy — NJ
S
T
W
Safeway
90
Target Pharmacy
90
Walgreens
Saint Joseph Mercy Pharmacy
90
Thrifty Drug Stores
90
Wal-Mart Pharmacy
90
Saker Shoprites
90
Sav-Mor Drug Stores
90
Tom Thumb Pharmacies
90
Wegmans Food Market
90
Save Mart Supermarkets
90
TOPS Markets
90
Weis Pharmacies
90
Schnucks Markets
Trihealth Pharmacy
90
Winn-Dixie Stores
90
Scott & White Health Plan
90
Shaws Supermarket
90
Shopko Pharmacy
90
Shoprite Supermarkets
90
Smiths Food & Drug Centers (Kroger)
90
University Medical Center
90
Snyder’s Drug Store
90
University of Utah Pharmacies
Southern Family Markets
90
US Bioservices
90
SRS
90
USA/Super D Drug
90
St Johns Mercy Pharmacies
90
Stephen L Lafrance Holdings
90
Stop & Shop Pharmacy
90
Super D Drugs
90
Supervalu Pharmacy
90
Pharmacy participates in Retail 90 Rx.
Times Supermarket
Weber & Judd
U
Ukrops Pharmacy
90
Z
90
Zallie Supermarkets
United Pharmacy — TX
University Of Wisconsin
V
Value Drugs — NY
90
Village Supermarkets
Von’s Pharmacy
Many independent pharmacies also participate in Retail 90 Rx, and additional chains join monthly.
For a complete and up-to-date listing, please call customer service.
www.optumrx.com
ORX0779A-INV_120714 ©2012 OptumRx, Inc.

Optum Rx Brochure

Transcription

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