Virtual Education Center

Your prescription drug list: what’s covered and how

Your plan’s prescription drug list (PDL) – also known as the “formulary” – lists all the medications covered by your plan, along with how they’re covered, making it a go-to resource whenever your doctor writes a prescription.

Check your plan’s May 2024 Essential PDL

Knowledge is wealth

Not only does your PDL help you explore your pharmacy benefits, it may also be the key to cost savings:

• The PDL is a dynamic document, so checking it often can help you avoid surprise changes in coverage.
• If your provider prescribes a medication that is not covered – or is, but is very expensive – checking your PDL gives you time to go back and discuss alternatives with the prescriber. You may find out, for instance, that there is a generic version of the drug – one that works the same but will cost you less.
• Another cost saving tip? Make sure your prescriptions are sent to a pharmacy in your network – otherwise you may be charged full retail price.

Filling prescriptions: as easy as 1-2-3

To help take the stress out of managing your meds, your plan gives you 3 ways to get or continue your prescriptions:

1. 
   Visit a network pharmacy. The OptumRx network gives you a broad range of pharmacies, some probably close to home. (And remember that staying in the network can save you money.)
2. 
   Set up home delivery by mail. Not only can enrolling in home delivery save you monthly trips to the pharmacy, but it may even save you money. You may be able to order up to a 3-month supply of your medication, and standard U.S. shipping is usually free.
3. 
   Download the mobile app. The UnitedHealthcare® app is your anytime, anywhere resource to:

   • Set up and refill home delivery orders
   • Track your prescription history
   • Find network pharmacies
   • Compare medication prices

Special prescription needs call for specialized support

If you’re on a specialty medication, it’s good to have personalized support – not only to help you find your medication, but to help you take it according to doctor’s orders, and to answer any questions that may come up.

Optum Specialty Pharmacy supports you with a team of pharmacists and nurses who specialize in your condition, and offers:

• The lowest cost on medications based on your plan
• 24/7 access to pharmacists
• Medication supplies at no extra cost
• Refill reminders
• Timely delivery, in confidential packaging

Common terms & FAQs

Useful pharmacy terms to know

• Prior authorization – a requirement that your doctor explain why you need a certain medication before your plan decides if, and how, it will be covered
• Specialty medications – medications used to treat complex or rare conditions that you may need to get from a specialty pharmacy
• Step therapy – when your plan requires you to try one or more medications before approving coverage for a different one
• Supply/quantity limits – the largest quantity of medication your plan will cover per copay or period of time – often limited for quality or safety reasons

Frequently asked questions

• How do I get my prescriptions filled when I’m away from home?

  Prescriptions can be filled at any network pharmacy. If you’re away from your home pharmacy, find your closest network pharmacy and call to fill your prescription.

• How do I get my medication from Optum Specialty Pharmacy?

  If you’re new to Optum Specialty Pharmacy and want to begin filling your prescriptions, sign in to your myuhc.com account to get more information or register here.
  
  The pharmacy offers convenient, free delivery to your home or wherever you prefer. We use experienced carriers to help ensure your medications are carefully shipped, including those that need special handling or refrigeration.

• How can I request prior authorization?

  To start the process, call the member phone number on your health plan ID card. Optum Rx will contact your doctor to help ensure your prescribed medication is the right one, is helpful to your condition, and is the correct dosage for you.

• Why isn’t my medication covered?

  Sometimes you may be prescribed a medication that isn’t covered by your plan. This may happen when a medication has been shown to offer no additional clinical and/or financial value over others in their class.
  
  Because we understand this can be disruptive for you or your family, we only exclude a prescription drug when it doesn’t meet specific clinical and savings criteria.

• What are prescription drug tiers?

  Tiers are the different cost levels you pay for a medication, as determined by your benefit plan. The prescription drug list (PDL) gives you choices so you and your doctor can determine the best course of treatment. Using lower-tier medications – if your plan is tiered – can help you pay the least out of pocket.

  Drug tier	Description	Cost
  Tier 1	Description: Medications that provide the highest overall value. While some brand-name prescription drugs may be included, these are mostly generics	Cost: $ (lower)
  Tier 2	Description: Medications that provide good overall value – mainly preferred brand-name prescription drugs	Cost: $$ (mid-range)
  Tier 3	Description: Medications that provide the lowest overall value. Many Tier 3 prescription drugs have lower-cost options in tiers 1 or 2, however, so ask your doctor if they could work for you.	Cost: $$$ (highest)

• What should I do about my prescriptions if a natural disaster happens?

  If you need help getting refills early or in the event of a crisis, speak to an advocate at the number on your ID card.