![]() Retail – Express Scripts Retail Network and Retail90 Prior Authorization from OSU Health Plan is required.Ĥ The deductible applies to brand name medications only.ĥ Retail90, also known as Smart90, is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.Įxpress Scripts offers prescription drug benefits through nationwide retail pharmacy locations and a home delivery mail-order service. 31, 2023 2023 Prescription Drug Benefit 1 PDF Versionġ Specific preferred insulin products will be available for a $25 copay per 34-day supply and a $75 copay per 90-day supply through the Express Scripts Patient Assurance Program only at Preferred Pharmacies.Ģ The Prescription Drug Benefit annual out-of-pocket maximum is based on benefit enrollment and is separate from the medical benefit annual out-of-pocket maximum.ģ Fertility treatment has a combined medical and pharmacy $15,000 lifetime maximum and is limited to a 30-day supply per fill. Please call or write:Ĭomplete details on filing a claim or appeal can be found in the Summary Plan Description (SPD).Effective Jan. urgent claim, prior authorization).įirst and second level appeals can be sent to Optum Rx. Optum Rx will decide your claim within the deadline for the type of claim involved (e.g. 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. The notice will be in writing and will inform you of the specific reasons for the decision. Optum Rx will provide you notice of the claim decision. 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. For each appeal, the member and provider will both get a letter of the determination.Ĭlaims are due within 12 months of the date of service. ![]() Optum Rx will contact the subscriber with instructions on submitting clinical information to support the script. Please call Optum Rx to appeal the rejection. If a claim is denied in whole or in part, you have the right to file an appeal. Non-Medicare members, ECP, BCN, HAP & Humana: 85Īlways present your medical ID card when at the pharmacy to ensure the correct information is submitted for your claim. Medicare members, TCN, BCN, HAP & Humana: 85 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).īlue Blue Shield Medicare Advantage members: 85 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. ![]() In most cases, you can order up to 90-days of prescription drugs at once. By using mail-order, prescriptions are delivered right to your home – plus shipping is free. The mail-order option is an easier, more convenient and cost-effective way to get your ongoing prescription medications. To locate participating network pharmacies near you, contact Optum Rx by phone or use the online pharmacy look-up tool. ![]() Retail pharmacies are also appropriate for situations in which your physician has not established the suitable drug, strength and dosage for ongoing needs. In most cases, unless your doctor has indicated “Dispense As Written” or DAW, your prescription will be filled with the generic equivalent.įilling Prescriptions: Retail Pharmacy or Mail-Order?įilling 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). ![]() On average, the cost of a generic drug is 80 to 85 percent lower than the brand-name product.įor the greatest cost-savings to you and the Trust, request that your doctor prescribe a generic drug. They offer all the same benefits as their brand-name counterpart at a fraction of the cost. Generic drugs are nothing new and are widely available and carefully regulated. Generic/Brand Name & Retail Pharmacy/Mail-Order Delivery ![]()
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