Prescription Drug Benefits
Prescription Drug Coverage is provided by Optum Rx. They are there to help make getting your medicine simple and cost-effective.
Show your pharmacy member ID card when you pick up a prescription. It will help you pay the lowest price for your medicine. Your Member ID card has contact information for questions about your pharmacy benefits. If you have not yet received a card or have misplaced it, you can print another by logging into the website, www.optumrx.com.
Home Delivery Program
Save money and time by getting certain medicines through the mail. The home delivery program brings your long-term medicine (those used to treat high blood pressure or high cholesterol for example) to your door.
You must pay for your mail order prescription prior to your order being shipped for any medications that exceeds $49.00. If you owe a balance or your new order exceeds that amount, it will not be sent until a method of payment is received by Optum. You can register a credit card and give permission to Optum to bill the credit card or you can enclose a check with your order. If your doctor submits a prescription electronically, it will not be filled until payment is made.
If using mail order, we encourage you to arrange for payment prior to submitting a prescription. Co-pay information is available on-line or by calling Customer Service.
If you wish to check the status of a drug, either for renewal, prior authorization or quantity limits please go to www.optumrx.com.
BriovaRx Specialty Pharmacy
BriovaRx, Optum’s Specialty Pharmacy, is included as part of your pharmacy benefit program for members who are receiving specialty medications. BriovaRx provides a hands-on service to help you get the special treatment you need for complex conditions including cancer, arthritis and others. To enroll or learn more about BriovaRx, please call 1-855-4Briova (1-855-427-4682) or visit www.BriovaRx.com.
Get answers about your prescription benefits 24 hours a day, seven days a week. The Customer Service number is 877-633-4461. Medicare Part D (EGWP) members should call 855-253-3270.
Members can log onto www.optumrx.com and after registering, can access information about your prescription drugs, such as: renew prescriptions, view your prescription drug history or print a temporary ID card to bring to the pharmacy.
Prescription Drug Co-Payments
Retail Mail Service
Tier 1 drugs Copayment $5.00 $10.00
Tier 2 drugs Copayment $25.00 $37.50
Tier 3 drugs Copayment $50.00 $75.00
Tier 4 drugs Copayment $75.00 $112.50
Certain specialty programs, including step therapy, prior authorizations, compound medications and quantity limits are based on FDA approved indications and Optum’s National Pharmacy & Therapeutics Committee recommendations. These programs were established to ensure safe, appropriate use of certain drugs and promote use of quality, cost effective medications.
Generic First (Step Therapy Program)
SSEHP requires prior authorization for first time users of certain drugs. This
Step Therapy Program requires the use of one or more Step One (Tier 1) medications (often a more affordable generic medication) that have been proven effective for most people with certain conditions before you can get a similar, more expensive, brand-name drug covered. This means that Step Two drugs (higher tiers) will not be covered under your drug benefit until Step One prescription drugs are first tried or your physician contacts Optum to obtain a prior authorization.
If you require a prior authorization for a Step Two drug, please call the Member Services Department at the telephone number listed on your Optum Rx member identification card.
If you already have an active prior authorization on file for a Step Two drug, or have tried a Step One drug, no action is needed.
If you are prescribed a medication that will be subject to the prior authorization process, you may request your physician to begin the prior authorization process at any time. When you refill your medication, a message will be sent to the pharmacy stating that a prior authorization is required.
You or the pharmacy may advise your physician to contact Optum at 877-633-4461 to begin the Prior Authorization process or you may provide Optum with the physician’s fax number and other appropriate information and Optum will contact the physician to begin the process.
Due to the increase in compound usage, the foremost concern that has arisen is one of patient safety. Unlike commercially-manufactured prescription medications, the U.S. Food and Drug Administration (FDA) does not oversee compounding, with the exception of new regulations for facilities producing sterile compounds in bulk. As a result, compound products are not approved by the FDA. As such, they are not subject to the same rigorous standards of quality, potency, purity, and stability in the manufacturing process as commercially-produced drugs. In addition, compounding regulations can vary significantly from state-to-state. Consequently, there is typically very little, if any, evidence from sound clinical studies supporting the safety and effectiveness of these products.
To address these concerns, SSEHP is working with Optum to better monitor and manage the safety and cost-effectiveness of compound medications for our members. Most of these compound medications take some time to prepare by the pharmacy and the new management process may require information exchange between the physician prescribing the medication and Catamaran. This information is meant to ensure that the
product ordered is safe, effective and within clinical guidelines for use.
If the drug prescribed for you exceeds the recommended quantity limit, a message will be sent to your pharmacy indicating that the quantity limit has been exceeded. The prescription must be re-submitted according to the quantity limit guidelines or you may ask that your physician be contacted to supply additional information regarding the quantity that is being requested.
For both Prior Authorization and Quantity Limits, you can check the list of drugs that are affected by calling Optum at 877-633-4461 or 855-253-3270. You may also visit our member website at www.optumrx.com.
If you ask that your physician be contacted, a fax will be sent to the prescribing physician requesting documentation of your diagnosis and other qualifying criteria. Once the physician completes and returns the form, a clinical pharmacist will review the information to determine whether the information meets the approval criteria. You, your physician and the pharmacy will be advised of the outcome.
Please note that the list of drugs that are subject to prior authorization or quantity limits may change over time. If you want to check the list in the future, you may call Optum or visit our member web site. Members already registered with will be required to enter their user name and password. New users will be required to create a user name and password.
Optum looks forward to providing you with superior pharmacy services. If you have any questions, please contact Optum at 877-633-4461 or 855-253-3270 for Medicare primary members.
As of July 1, 2019, all members will be subject to a 30 day supply limitation on certain high cost prescription drugs (drugs which cost $670 or more). For a list of medications, please see SSEHP.org, or
If you have any questions about a medication you are currently taking please call the Toll Free Number on the back of your ID card. The Toll Free Number for the Commercial (Non-Medicare) Plan is 1-877-633-4461. The Toll Free Number for the Medicare Plan is 1- 855- 253-3270.