•Welcome to Chapter 3C – Pharmacy Coverage
•As a reminder, please remember:
• All Chapters provided in the 2015 Benefits Guide are intended to be
part of a module series
•There are eight Chapters, several of which contain sub-chapters
• Follow along with and compile these into your own presentation
(see below) in the order they are presented
• Text items in red are variables. Please modify them as necessary in
order to fit your presentation’s and consumers’ needs
• Please pick and choose from the slides provided to create a custom
presentation that is right for you and your consumers. To do this, refer
to the instructions listed on the end slide of each Chapter
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Pharmacy Coverage
Your pharmacy benefit offers you access to:
•
Affordable medications
•
•
Choice of Pharmacy:
•
•
A number of affordable brand and generic medications
Thousands of retail pharmacies, including national
chains, many community pharmacies plus the
OptumRx® Mail Service Pharmacy
24/7 Personal Support:
•
Benefit information, savings and lower cost alternatives
online or by talking to a pharmacist or benefit specialist
24 hours a day, 7 days a week
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Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Looking for ways to lower
the cost of your
prescription drugs?
AFFORDABLE MEDICATIONS
Prescription Drug List (PDL) – A list of brand and generic medications
approved by the U.S. Food and Drug Administration (FDA)
$
Tier 1
$$
Tier 2
$$$
Prescription
medications are
placed into tiers
based on their
overall value.
Tier 3
Tier levels
determine the
amount paid when a
prescription is filled.
Typically generics
Exclusions
•
When lower-cost options are available, the higher-cost option from coverage under the
pharmacy benefit may be excluded
•
If you are taking an excluded medication, check the “Drug Pricing” tool found under
“Manage My Prescriptions” on myuhc.com®
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Confidential property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
CLINICAL PROGRAMS
Promoting safety and appropriate use
Notification
or Prior
Authorization
• Requires your doctor to tell us why you are taking your medication in order to
determine if you will receive benefit coverage
• To start the process talk to your doctor. Once we review the information, we will
send you and your doctor a letter to let you know if the medication is covered
Supply
Limits
• A supply limit is the largest quantity of medication covered per copayment or in
a time period
• Based on FDA guidelines for medication dosage, clinical guidelines or usage
patterns
Step
Therapy
• With this program you
need to try a lower-cost
medication first, before a
higher-cost medication
may be covered
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Confidential property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
FINDING YOUR PHARMACY
Access to pharmacy network and OptumRx Mail Service Pharmacy
Retail Pharmacy Network
•
Thousands of retail pharmacies, including
large national chains, many community
pharmacies
OptumRx Mail Service Pharmacy
•
Receive home delivery of your
medication with free standard shipping
•
Speak to a pharmacist who can answer
your questions anytime, any day
•
Set up text and email reminders to help
you remember to take or refill a
medication
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OPTUMRx MAIL SERVICE PHARMACY
How to Enroll in Home Delivery
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Confidential property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PHARMACY COSTS
Retail
$
Tier 1
$__ Member Cost
Mail Order
$__ Member Cost
1-month supply
$$
Tier 2
$$$
Tier 3
$__ Member Cost
3-month supply
$__ Member Cost
1-month supply
$__ Member Cost
3-month supply
$__ Member Cost
1-month supply
This is the current copayment/coinsurance structure of the plan in effect today. These amounts are subject to change.
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3-month supply
YOUR PERSONAL RESOURCES
We provide resources available to help you anywhere, anytime
Visit www.myuhc.com to
manage your prescriptions,
look up nearby pharmacies,
and access the PDL list
Our mobile website provides
text messages and medication
reminders in addition to our
web resources
Call the number on the back
of your ID card for 24/7 call
support to answer pharmacy
and medical questions
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SPECIALTY PHARMACY
We focus on you and the total condition, not just drug utilization
Conditions Include:
Cancer, Hemophilia, Hepatitis C, Multiple
Sclerosis, Rheumatoid Arthritis, HIV and more
Services:
•
24/7 access to pharmacies, providing
support focused on you
•
Adherence and clinical programs to help
you better manage your condition
•
Proactive reminders and timely delivery
•
Online support and medication information
for you
Our Specialty Pharmacy Program provides the resources and the condition-specific support you need to
help you manage your complex conditions and achieve your best health.
9
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PHARMACY PAYMENT PROCESS
1
Present health
plan ID card
to pharmacy.
2
Pharmacy
verifies
eligibility
and any
amount you
owe at the
point of sale.
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3
You pay your
member cost
responsibility
for
medications
covered under
your
pharmacy
benefit.
MAIL SERVICE MEMBER SELECT
If you are currently taking medication on a regular basis –
you have an important decision to make.
•
Effective 1/1/2015, you are already enrolled in Mail Service Member Select and can
begin realizing the benefits of home delivery immediately.
•
You must choose to either fill your maintenance medication through the OptumRx Mail
Service Pharmacy or through a retail pharmacy.
•
If you choose a retail pharmacy you must disenroll from Mail Service Member Select.
•
Mail Service Member Select allows you two retail pharmacy refills of your
maintenance medication before you have to decide.
•
If you do not take action after the second retail fill you will pay 100% of the drug cost
until you make a decision.
•
If you choose not to take advantage of the mail service pharmacy and disenroll, you
may continue filling medications at a retail pharmacy for your standard copay or cost..
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SELECT DESIGNATED PHARMACY
Participants choose one of three options to continue receiving
network benefits
A
Move to a lower-cost medication and save up
to $480 per year
Saving you and your
members money
There are often many medications that treat the same
condition. Members should consider a lower-cost option.
Average employer savings
Use mail service and save up to $90 per year
B
Members who want to keep taking their current
medication can -- through the convenient mail service
pharmacy.
$0.63
PMPM
Average member savings
Do both and save up to $500 per year
C
For the most savings, use a lower-cost medication and
mail service.
$360
annually
Members on affected drugs who have non-network benefit coverage and choose to make no change will pay the full cost of the drug, and can file a paper claim for reimbursement as an
non-network benefit. Potential savings estimates are based on UnitedHealthcare typical benefit designs and are calculated based on an average 30-day supply for retail or a 90-day supply
for mail service. Actual savings may vary. Average savings based on BoB plan results from Q1-Q3 2012.
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SELECT DESIGNATED PHARMACY
Member Engagement
Helping members understand their choices
Letters explaining the program (after grace fill #1)
Automated phone call about the program (after grace
fill #1)
Point-of-sale message, delivered by the pharmacist
(after grace fills #1 and #2)
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SELECT DESIGNATED PHARMACY
Advantage PDL Program Medications
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SELECT DESIGNATED PHARMACY
Traditional PDL Program Medications
15
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•This ends Chapter 3C – Pharmacy Coverage
•Please open Chapter 4A – Choice Plus Plan
•Copy and Paste slides from Chapter 4A to this Power Point
(Chapter 1)
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5. Right click there and select Copy—Use Source Formatting
•Whichever slides from Chapter 4A that do not apply to your
customer, delete
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