Prescription Drug

If you are participating in either the Aetna PPO or HDHP Plan, your prescription drug “Rx” coverage is NOT provided by Aetna, but rather by OptumRx, our Pharmacy Benefit Manager (PBM). Eligibility for the Rx program is the same as that for the medical program. As soon as you enroll for either of the Aetna medical plans noted above, you will also be enrolled in the OptumRx prescription drug program. NOTE: you will receive separate ID cards. Do not use your Aetna ID card for prescription drugs, rather, always use your OptumRx ID card for prescriptions.

Employee contributions are included in the medical plan contributions.

Copays and coinsurance for prescription drugs, after the annual deductible has been satisfied (where applicable):

 

 

Retail (30 day) at any Participating Retail Pharmacy

Retail (90 day) at Walgreen’s/Duane Reade Only

Mail

Tier 1 (Generic)

10% coinsurance, minimum $7.50 copay/ maximum $30 copay

10% coinsurance, minimum $15 copay/ maximum $60 copay

10% coinsurance, minimum $15 copay/ maximum $60 copay

Tier 2 (Preferred Brand)

20% coinsurance, minimum $20 copay/maximum $100 copay

20% coinsurance, minimum $40 copay/maximum $200 copay

20% coinsurance, minimum $40 copay/maximum $200 copay

Tier 3 (Non-Preferred Brand)

30% coinsurance, minimum $40 copay/maximum $200 copay

30% coinsurance, minimum $80 copay/maximum $400 copay

30% coinsurance, minimum $80 copay/maximum $400 copay

Specialty

30 Days' Supply Limit at Optum Specialty (formerly Briova) Mail

Generics: 10% coinsurance, minimum $15 copay/maximum $60 copay

Preferred Brands: 20% coinsurance, minimum $40 copay/maximum $200 copay

Non-Preferred Brands: 30% coinsurance, minimum $80 copay/maximum $400 copay

 

More than 30 Days' Supply Limit at Optum Specialty (formerly Briova) Mail, only for select specialty drug classes

Generics: 10% coinsurance, minimum $30 copay/maximum $120 copay

Preferred Brands: 20% coinsurance, minimum $80 copay/maximum $400 copay

Non-Preferred Brands: 30% coinsurance, minimum $160 copay/maximum $800 copay

 

 

Prescription Plan Features

Price Edge -- New for 2024: Price Edge is a simple way for members to save on non-specialty, generic drugs covered or not. The OptumRx claim system will scan discount card market pricing and compare it to the benefit, providing a competitive price. You will have an improved member experience because OptumRx will retain your medical history for drug and clinical programs. 

Network: OptumRx has a well-established national network of pharmacies through which you may fill prescriptions. If you use one of OptumRx’s participating pharmacies, your out-of-pocket costs may be lower than if you use a non-participating pharmacy. You can obtain an up to date listing of participating pharmacies by visiting the OptumRx web site at www.OptumRx.com. You can also call OptumRx at 866-837-9242. Be sure to register at the OptumRx website, so that you have access to your medication information easily online; you can order renewals, print out ID cards, etc.

When obtaining your prescriptions, you can receive up to a 30-day supply at a retail Participating Pharmacy or up to a 90-day supply at OptumRx mail order. You can also receive a 90-day supply from Walgreens or Duane Reade. Specialty drugs must be obtained through Optum Specialty and have varying day supply requisites.

Formulary: OptumRx has negotiated preferred pricing on certain drugs, included on a list called a formulary. As a result of this preferred pricing (which is often on drugs by different manufacturers for the same medical condition), lower co-payments are offered on the formulary drugs. You can obtain a copy of the formulary by contacting OptumRx at the phone number or web site shown above. Formulary information is subject to change based on drug updates or market changes. Therefore, using the app, website or customer service is the best way to confirm pricing and tier placement/exclusion.

Mail Order Program: The mail order program is designed to be more convenient and less expensive for you to obtain medications you take on an ongoing basis, such as those used to treat chronic conditions.

Your co-payment per prescription will be 10% coinsurance, minimum copay $15 and maximum copay $60 for each generic drug obtained. If there is no generic equivalent and you can use a drug on the Formulary, you will pay 20% of the Pharmacy Payment Rate, with a minimum of $40 and maximum of $200. If you obtain a non-formulary drug, you will pay 30% of the Pharmacy Payment Rate, with a minimum of $80 and maximum of $400.

If you insist on a brand name prescription drug when there is a generic equivalent and your physician does not indicate “Dispense As Written,” you will be responsible for the cost difference between the brand name drug and its generic equivalent, plus the applicable co-payment or coinsurance.

Specialty Drug Program: In addition to the existing retail pharmacy network, OptumRx contracts with a specialty pharmacy, Optum Specialty (formerly known as Briova). Optum Specialty can help you fill a new prescription. Please call Optum Specialty at 855-427-4682.

Step-Therapy: For certain prescriptions, participants are required to first try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug that the doctor may have prescribed.

The generic equivalent of the prescription drug will be dispensed to you at a cost of 10% coinsurance, minimum $7.50 copay/ maximum $30 copay.

If there is no generic equivalent and you can use a drug on the Formulary, at retail for 30 day supply you will pay 20% of the Pharmacy Payment Rate, with a minimum of $20 and maximum of $100. If you obtain a non-formulary drug, you will pay 30% of the Pharmacy Payment Rate, with a minimum of $40 and maximum of $200.

If you insist on a brand name prescription drug when there is a generic equivalent and your physician does not indicate “Dispense As Written,” you will be responsible for the cost difference between the brand name drug and its generic equivalent, plus the applicable co-payment or coinsurance.

Clinical Utilization Management

Prior Authorization, Fill Limits, and Exclusions: Some prescription drug medications are subject to prior authorization, to limitations on the amount for which the prescription will be filled, or to exclusions under this Plan. For a complete list of these medications, contact OptumRx.

Copay Card Accumulator Adjustment Program and Variable Copay Program: The copay card accumulator adjustment program provides that copay assistance program amounts will not count towards the member’s cost share for the deductible and out of pocket maximum. The variable copay program allows members to receive maximum benefits from copay assistance programs by paying the copay indicated by the copay assistance program and not more than the current specialty design cost share.

Split Fill and Smart Fill Programs plus 30 Days’ Supply Limit on Specialty Drugs:
The Split Fill Program for Oral Oncology Medications fills half the prescription twice a month, rather than a full prescription once a month, when a patients starts a new regimen of oral oncology medications. Patients who tolerate the new drug for three months will be eligible for the standard days’ supply for duration of therapy. Member copays would be pro-rated to reflect the lower days’ supply.

The Smart Fill Program allows 90 days’ supply fill for select specialty drug classes Multiple Sclerosis, Inflammatory Conditions, and Transplant drug classes. 

There is a 30 days' supply limit on non-smart fill program specialty drugs.

Claims and Appeals: Claims and appeals should be submitted to OptumRx, at the address available through the website, telephone, or on your OptumRx prescription drug card.

Additional Information. Please note that Formulary information is subject to change based on drug updates or market changes. Therefore, using the app, website or customer service is the best way to confirm pricing and tier placement/exclusion. 

Under the Aetna HDHP with HSA, prescription drugs are grouped into preventive and non-preventive medications.

  • For non-preventive medications, you pay the full cost of the drug (after OptumRx discounts are applied) at the time of purchase. Non-preventive medication expenses do apply to the deductible. Go to OptumRx to search for all covered drugs under the Plan and see how much they cost.  
  • Once you meet your annual deductible, you pay the applicable copay or coinsurance.

There is no separate out-of-pocket maximum for prescription drugs under the HDHP.

Learn more about the HDHP with HSA.

Under the Aetna PPO, prescription drugs are grouped into preventive and non-preventive medications.

  • For non-preventive medications, you pay the full cost of the drug (after OptumRx discounts are applied) at the time of purchase. Non-preventive medication expenses do apply to the deductible. Go to OptumRx to search for all covered drugs under the Plan and see how much they cost.  
  • Once you meet your annual deductible, you pay the applicable copay or coinsurance.

There is no separate out-of-pocket maximum for prescription drugs under the PPO.

Learn more about the Aetna PPO.

This brochure contains information about the medical plan options and other benefits Segal Group offers. If any statements contained herein are inconsistent with applicable laws and regulations or official plan documents and contracts, those regulations and documents will govern. Segal Group reserves the right to amend or terminate any plan, at any time, for any reason. No provision of any benefit is to be considered a contract of employment between you and Segal Group.

© 2024-2025 by The Segal Group, Inc. The information in this overview offers only brief highlights of the 2019 benefits plans. In the event of a conflict between this overview and the plan documents or policies, the plan documents or policies will govern.

Save Money with Generic Medication

Generic medications generally cost less than brand-name drugs. Generics can be as effective and safe as their brand-name counterparts, so be sure to discuss your options with your doctor.