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Prescription Drug Benefits

Optum Rx


Optum Rx manages the pharmacy benefit for Suffolk School Employees Health

Plan employees and covered family members.

What pharmacy can I use?

The Optum Rx Pharmacy Network is comprised of major chains, grocery store pharmacies, and many independent pharmacies throughout the United States. You can use the Pharmacy locator tool at to find pharmacies nearest you.


What medication does the prescription drug list include?

The prescription drug list includes commonly prescribed medications. You can use the drug list to see if a medication is covered by your health insurance plan. You can also find out if a medication is available as a generic, needs prior authorization, has quantity limits and more.


Why could my coverage or cost change?

Your coverage or cost could change for a few reasons. Examples include:

• A change in your annual deductible.


• Medications moving to a different tier or are no longer covered.


• You may be required to get a prior authorization from

your provider or try other medications first (step therapy).


• Medications may only be covered in certain quantities

(quantity limits) or for a specified time period.


How does Optum Home Delivery work?

Home delivery lets you order up to a 90-day supply of medications you take regularly. You can submit your order online, through the app, by phone, or ask your doctor to send us an electronic prescription. Optum® Home Delivery fills your order, ships it to you, and lets you know when to expect delivery.


What is a prior authorization?

Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine if it will be covered under your pharmacy benefit. Some medications must be reviewed because they may:

• Only be approved or effective for safely treating specific conditions.

• Cost more than other medications used to treat the same or similar conditions.


How can I find out if my medication requires a PA?

• Your pharmacist will tell you if a PA is required.


• You can call Optum Rx at the number on your member ID card.


• You can also look online.

· Log into > Member tools


· Click on Drug pricing and information


· Enter the drug name and dose


· If the drug/dose you entered needs a prior authorization, you will see an alert below the drug name stating a PA is required.


What do I do if my medication needs a PA?

To begin the PA process, do any of the following:


• Let your doctor know that a PA is needed for your medication. They will submit the required information to Optum.

• Call the number on your member ID card.


• Log into, go to Benefits and claims, and click on Prior authorization or exception request.


How long does it take for a PA to be approved or denied?

Once your PA has been submitted and received, it usually takes up to 24 hours to process. If your PA request needs additional review, it may take longer.


How do I know if my medication has been approved and what happens next?

We will send a letter to you and your doctor letting you know if your medication coverage is approved or denied. You can also check the status of your PA by signing into, going to Benefits and claims and clicking on Prior authorization or exception requests. You will see the status of any active PAs in process. If your medication is approved, coverage will be provided under your benefit. You can continue to fill your prescription at the pharmacy as usual during the approved PA period. If your medication is denied, we’ll send a letter telling you why and provide information about the appeal process.


What are specialty medications?

An injected, infused, oral or inhaled medication is defined as a specialty medication if it:

• May need ongoing clinical oversight and extra education.


• Has unique storage or shipping needs.


• May not be available at retail pharmacies.


• May need infusion or home nursing.


Who do I contact with questions about my specialty medication?

Call 1-855-427-4682. Pharmacists and patient

care coordinators are available 24/7 to take care of everything, including:

• Transferring your prescription.


• Helping you find affordable ways to get your medication.


• Explaining how to use the specialty pharmacy.


Anytime help:

Get answers about your prescript on benefit 24 hours a day seven days a week. The Customer Service number is 1-877-633-4461. Medicare Part D (EGWP) members should call 1-855-253-3270.

Members can log onto and after registering, can you access information about your prescription drugs, such as: new prescription, view your prescription drug history or print temporary ID card to bring to the pharmacy.

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