Frequently asked questions about pharmacy coverage

Rx is a common abbreviation or symbol that health care providers and pharmacists use for prescription medications.

A formulary (also called a Prescription Drug List) is a list of prescription medications covered by your health plan or prescription drug benefit. The medications on this list are considered formulary drugs.

• Brand-name drugs are sold under the name of the company that made them. They are also protected by a patent. A brand-name drug can only be sold by the company holding the patent.
• Generic drugs are copies of brand-name drugs. A generic drug is required to have the same active ingredient, strength and dosage as the brand-name drug. It must also be taken the same way. Generic drugs typically cost less than brand-name drugs.

These are types of medications you can get without a prescription. Examples include pain relivers and personal care products. Visit the Optum Store to conveniently shop for over-the-counter medications and more.

This is the largest amount of medication your plan will cover per copay or period of time. Some medications have quantity limits for safety reasons.

Sometimes, your plan may require that you try one or more medications to treat a condition before approving coverage for a different medication. This is called step therapy.

Medications used to treat complex or rare conditions are called specialty medications. You may need to get these medications from a specialty pharmacy, such as Optum Specialty Pharmacy.

This is a type of network pharmacy where members may have a lower copay and other savings for covered prescription drugs than a standard network pharmacy. Sign in to your member account to view your plan’s preferred network pharmacies.

Some medications need prior authorization. This means your doctor must provide information to your plan about why you need the medication. A prior authorization is an approval your plan must give before your medication can be covered.

Your doctor can start the prior authorization process. Or you can call the number on your member ID card and Optum Rx^@ will contact your doctor.

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, determined by your benefit plan. This is how much you pay when you fill a prescription. Your plan’s Prescription Drug List, also known as a formulary, gives you choices so you and your doctor can determine the best course of treatment. Using lower tier medications can help you pay lower out-of-pocket costs. Below is an example of a 3-tier plan; your plan may have a different number of tiers.

Review your plan’s Prescription Drug List (PDL), also called a formulary. The PDL is a list of medications that shows how they’re covered by your plan. If you have a prescription for a certain kind of medication, you can look it up in your PDL to see how it’s covered.

When your doctor prescribes medication, look at your Prescription Drug List (PDL) and talk about the cost. You can ask about lower cost alternatives if the drug your doctor chooses is too expensive or isn’t covered. A similar or generic version of the drug may often work just as well.

In some cases, you may be prescribed a medication that is not covered by your plan.

This could happen because medications have been shown to offer no additional clinical and/or financial value over others in their class. In that case, they may not be covered under your plan. However, we understand this can be disruptive for members, so we only exclude a drug when it meets specific clinical and savings criteria.

You can find more information about specific prescription drug coverage by signing in to your member account.

You can search the Optum Rx pharmacy network to view general network pharmacy locations. Make sure to confirm your plan’s specific coverage details before filling a prescription. Sign in to your account to view your prescription benefit details. Members can also view plan details with the UnitedHealthcare app.

You can fill prescriptions at any network pharmacy. If you’re traveling and away from your home pharmacy, find your closest network pharmacy and call the pharmacy to fill your prescription.

• If you're new to Optum Specialty Pharmacy and want to begin filling your prescriptions, start your fill.
• If you’re a current patient, sign in and request a prescription refill. Once Optum Specialty Pharmacy receives your request, their pharmacy team will work with you and your doctor's office to fill your prescription and provide knowledgeable assistance and education.

Optum Specialty Pharmacy offers convenient delivery of medications directly to your home or preferred location. They use experienced carriers to help ensure your medications are carefully shipped. If your medications require special handling or refrigeration, they will be packed and shipped accordingly. There is no cost for standard shipping or handling.

Call the number on your member ID card and tell the representative you’ve been affected by a disaster. They can answer your questions and help you get early refills for your prescriptions if needed.

Medicare Part D drug coverage helps cover some or all of the costs of prescription drugs that are not covered under Medicare Parts A & B, or Original Medicare (i.e., drugs administered during hospital or doctor visits). Many people who qualify for Medicare Parts A & B choose to supplement that coverage with a Medicare Part D prescription drug plan.

It’s a good idea to enroll in Medicare Part D as soon as you’re eligible — even if you may not need prescription drug coverage yet — to avoid paying a late enrollment penalty on your premium.

Medicare Part D plans offer coverage for both generic and brand name prescription drugs on a list called a formulary. The formulary includes at least two drugs in the most commonly prescribed categories and classes, but Part D plans can choose which drugs covered by Part D they will offer. Be sure to verify that your prescriptions are covered on the plan’s formulary or list of covered medications (also called a Prescription Drug List).

Sign in to your member account to find more information about your specific prescription drug coverage. Not a member? Explore UnitedHealthcare and Medicare Part D plan options where you live.

Medicare Part D drug coverage is optional and is offered to everyone with Medicare. However, you must be enrolled in Medicare Part A and/or Part B to enroll in a Medicare Part D plan. You must also be:

• A United States resident and a U.S. citizen or alien who has been lawfully admitted for permanent residence
• Residing in the U.S. for 5 continuous years prior to the month of filing an application for Medicare

Additionally, you’ll need to meet one of the following eligibility requirements:

• Age 65 or older;
• Younger than 65 with a qualifying disability; or
• Any age with a diagnosis of end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s disease)

It’s a good idea to enroll in Medicare Part D as soon as you’re eligible — even if you may not need prescription drug coverage yet — to avoid paying a late enrollment penalty on your premium.

Most Medicaid plans cover some prescription drugs. But exactly which ones can change from state to state. Also, different states may have different rules for copayments and cost sharing, so the cost of the medicines may change based on the state.

You’re eligible for a D-SNP if you qualify for both Medicaid and Medicare. A D-SNP is a type of Medicare Advantage plan that includes Medicare Part D. That means you could get more prescription drug coverage than you may have now with only Medicaid or Original Medicare plans.

Sign in to your member account to find more information about your specific prescription drug coverage.

Learn more about the UnitedHealthcare Dual Complete® health plan