Prescription Coverage
Our prescription benefits are provided by OptumRx and administered by RxBenefits, Inc. There are more than 64,000 pharmacies in your pharmacy network.
You may access a copy of the most recent preferred drug list and formulary exclusions at www.optumrx.com or by contacting RxBenefits at 1-800-334-8134.
Tiered Cost of Rx
| Retail Pharmacy (30 Day Supply) | ||
|---|---|---|
| Generic (Tier 1) | $10 copay | |
| Preferred (Tier 2) | 30% to $100 | |
| Non-Preferred (Tier 3) | 50% to $250 | |
| Retail Pharmacy (90 Day Supply) | ||
| Generic (Tier 1) | $30 copay | |
| Preferred (Tier 2) | 30% to $300 | |
| Non-Preferred (Tier 3) | 50% to $750 | |
Mail Order
| Retail Pharmacy (30 Day Supply) | ||
|---|---|---|
| Mail Order Pharmacy (90 Day Supply) | ||
| Generic (Tier 1) | $20 copay | |
| Preferred (Tier 2) | 30% to $200 | |
| Non-Preferred (Tier 3) | 50% to $500 | |
Specialty Medications
| Retail Pharmacy (30 Day Supply) | ||
|---|---|---|
| Specialty Medications (30 Day Supply) | ||
| Specialty medications must be ordered through Briova Rx at 1-800-850-9122 and are limited to a 30 day supply | 50% to $250 | |
2024-2025 Medical and Rx SBC
Video: Prescription Drug Benefits
