BEFORE JANUARY 1, 2018
Member Phone: 1-844-368-8740
Monday through Friday, 8am-8pm, CST
App for your smartphone: OptumRx
AFTER JANUARY 1, 2018
Member Phone: 1-844-368-8740
24 hours a day, seven days a week
App for your smartphone: OptumRx
Who is OptumRx and when will the change to OptumRx take place?
OptumRx will be your plan’s pharmacy care services manager. The change to OptumRx from Express Scripts will take place on January 1, 2018.
Will I receive a new pharmacy ID card?
Yes, you’ll receive a new member ID card and welcome materials a few weeks before your plan becomes effective on January 1, 2018
Will the medication I’m currently taking be covered with OptumRx?
Yes, the vast majority of the prescriptions filled under Express Scripts will be covered by OptumRx. Those medications prescribed for off-label usage that were fillled by Express Scripts may be flagged by OptumRx. Any medications that have been pre-approved under Express Scripts will also be honored by OptumRx.
How does the appeals process work with OptumRx?
The appeals process will continue to be a three-level process with the third level being an independent review.
Can I still take a brand medication if a generic is available?
Yes. Your pharmacy will fill prescriptions with a generic medication until otherwise told by the doctor or if the member requests brand.
Will I be required to use mail order under Optum RX?
No, unless you use a drug that can only be filled via Specialty Pharmacy.
How will I fill my prescription at a retail pharmacy?
On or after January 1, 2018, choose a pharmacy in your plan’s network and present your member ID card at the pharmacy counter. The retail pharmacy does not need a new prescription as long as you still have refills on your script.
With OptumRx, can I continue to go to the same pharmacy?
Most likely, yes. You will have access to a large network of retail pharmacies, including large national chains and many local pharmacies. To see a list of network pharmacies in your area, use the OptumRx app, visit the website on your member ID card or call customer service. Some retail pharmacies fill a 90-day supply.
Will that be available through OptumRx? If so, which pharmacies?
Members may be able to fill 90-day prescriptions at a retail pharmacy by paying 3x the retail copayment. The member should check with their retail pharmacy to determine whether this is possible with the specific medications.
PREFERRED AND NON-PREFERRED DRUGS
What is a preferred versus non-preferred drug?
Some plans in the SEHBP have lower copays for preferred brand drugs and higher copays for non-preferred brand drugs.
Will a list be available to check whether a medication is preferred or non-preferred?
Yes. To learn if your prescription is a preferred or non-preferred brand, check online at optumrx.com/stateofnewjersey. Members may check on the app after January 1, 2018.
Will the same preferred drug list be used under OptumRx that was used by Express Scripts?
No, the OptumRx preferred drug list is not the same as Express Scripts’ preferred drug list.
Will my out-of-pocket costs change under OptumRx?
Possibly. The preferred status of medications could change with the switch to OptumRx. The medications on the preferred list do change periodically.
Will there be any changes to the current step therapy program?
The therapeutic categories that require step therapy will not change under OptumRx. However the individual drugs impacted within that category may be different based upon OptumRx’s preferred drug list.
If I have already tried and failed to use the less expensive drug under the Express Scripts step therapy program, will this be honored by OptumRx?
Yes. OptumRx will be receiving a file of all members who have already gone through the authorization process with Express Scripts. Please note that only active authorizations that have not expired will be transferred.
Will there be any changes to the compound medication procedure put in place by the SEHBP Plan Design Committee?
No. The compound medication changes that were approved by the SEHBP Plan Design Committee will continue under OptumRx. The procedure for approving compound medications will not change and the exclusion lists are regularly updated.
How are diabetic prescriptions and supplies (strips and lancets) covered under the new plan?
The only change would be if the supplies are listed as a preferred or non-preferred.
I don’t have a prescription card, but a 10% copayment plan? For active members who pay their portion of the prescription costs through coinsurance, will the out-of-pocket costs at the pharmacy change?
Maybe. Coinsurance is based on the contracted rates between the pharmacy and the current prescription PBM, Express Scripts. OptumRx’s contracted rates may be different than what they were under Express Scripts.
HOME DELIVERY (MAIL ORDER)
Will OptumRx have an automatic refills program like Express Scripts for maintenance medications? If so, will Express Scripts forward medication and doctor information to OptumRx?
OptumRx does have a Hassle Free program that allows members to put their medication(s) on automatic refill. While the prescription itself will be automatically transferred to OptumRx, your billing information will not be transferred. Members will have to have this turned on through the OptumRx website or by contacting member services on or after January 1, 2018.
Will my home delivery prescription(s) transfer to OptumRx?
Most home delivery prescription(s) with remaining refills will automatically transfer. Prescriptions for certain medications will not transfer. Examples include controlled substances and prescriptions that have expired. In these cases, you’ll need a new prescription from your doctor.
Will my billing information also transfer to OptumRx?
No. Before OptumRx can ship your first home delivery order, you will need to set up your credit card or billing preference with OptumRx.
If I currently do not have home delivery and would like start it with OptumRx, how do I order my prescriptions?
Once your coverage begins, here are four ways to place a home delivery order:
Once I place a home delivery order, how quickly will I get my medication?
New and refill prescription orders are delivered by standard U.S. mail and will arrive within 7 to 10 days from the date OptumRx receives the completed form.
Will I be able to manage my home delivery prescriptions online?
Yes. After your plan moves to OptumRx, you will be able to access your prescription and home delivery information online or through the mobile app.
Who is BriovaRx?
BriovaRx is the OptumRx specialty pharmacy.
Do I have to use BriovaRx?
Yes, for specialty medications.
How will I receive my specialty medication from BriovaRx?
Your specialty medication is shipped wherever you need it – in safe, temperaturecontrolled and tested packaging.
Will my specialty medication automatically transfer to BriovaRx?
No, your specialty medication will not automatically transfer to the OptumRx specialty pharmacy. However, you may choose to have your specialty medication transferred to BriovaRx after your coverage starts. Once coverage begins (January 1, 2018), call a BriovaRx representative at 1-855-4BRIOVA to enroll. You can also register online at https://specialty.optumrx.com/. BriovaRx representatives will contact your doctor and take care of everything else.