Active Members and non-Medicare Retirees

These prescriptions can be filled at any in-network pharmacy (CVS, Target, Walgreens etc.).  To locate an in-network pharmacy closest to you, register on www.optumrx.com (linked above) and access the Pharmacy Locator icon, your personalized Medicine Cabinet, OptumRx Home Delivery Pharmacy, and much more!

You may receive up to two 30-day supplies of a short-term medication, but if you seek a third refill of that medication it is no longer considered short-term. When seeking a third refill it is now considered a long-term medication (maintenance medication), and you must transition to a CVS retail pharmacy or the OptumRx Home Delivery pharmacy to obtain a 90-day supply. You do have the option to stay at your
current pharmacy for that refill; however, for any future refills you will be responsible to pay 100% of the cost of the medication. Please note, if you choose to pay the 100% of the cost no reimbursement will be allowed.

These prescriptions must be filled at a CVS retail pharmacy or through the OptumRx Home Delivery pharmacy for a 90-day supply. Please note that all prescriptions must be written for a 90-day supply when using the OptumRx Home Delivery Pharmacy. If the prescription is written for anything less than 90-days, you will still be responsible for paying a 90-day copayment.

• Let your physician know if you would like to use a CVS retail pharmacy or the OptumRx Home Delivery pharmacy so they can accurately submit your prescriptions.
• For assistance regarding OptumRx Home Delivery, you can contact their Customer Care Call Center
  at (855) 697-9150.

Our program offers a convenient 4-tier structure.  If the cost of the medication is less than your copay, you are only responsible for paying the lower amount. Please refer to your Summary Plan Description and/or Schedule of Benefits for the copay associated with the tiers outlined below:
• Generic Medication (Tier 1)
• Preferred Brand Name Medication (Tier 2)
• Non-preferred Brand Name Medication (Tier 3)
• Specialty Medication (Tier 4)

For this population, we follow the OptumRx Select Formulary list (linked at top of page).  This is a guide within select therapeutic categories for Plan members and health care providers. Ask your physician to consider prescribing generic medication as a first line option, when medically appropriate. Generic medications are typically a lower cost to the plan, and these savings are immediately passed directly to the membership. If there is no generic available, there may be a preferred brand name medication listed.

When available, generic medications will be substituted for all brand name medications. If you request the brand name, or if the prescribing physician indicates “no substitutions”, when a generic equivalent is available, you will be required to pay the brand name copay plus the difference in cost between the  brand and its generic equivalent, unless determined medically necessary through the appeals process.

If your prescription is rejecting due to a PA required, the pharmacy should reach out to your physician.  In the event that your physician does not receive this information from the pharmacy or you would like to expedite the PA process, we recommend that you follow up with your physician’s office.

Your physician can initiate a PA with OptumRx by doing any of the following:

• Call the OptumRx PA department at (800) 711-4555
• Electronic (ePA):https://www.covermymeds.com/epa/optumrx/

All PA’s are reviewed by clinicians at OptumRx, not the Pharmacy Benefit Department at the Fund Office.

If you would like to check on the status of your PA, contact OptumRx Customer Care Call Center at (855) 697-9150.

Active Plans ONLY:

The Plan provides coverage for certain Preventive Care Medications as required by the ACA. Coverage is provided on an in-network basis only, with $0 cost-sharing for the member.

Coverage for certain prescribed and over-the-counter preventive care medication include:

• Medicine and supplements to prevent certain health conditions for adults, women and children;
• Human Immunodeficiency Virus (HIV) Preventive Medications;
• Statin Preventive Medications;
• Medicine and products for quitting smoking or chewing tobacco (tobacco cessation);
• Medicine used prior to screenings for certain health conditions in adults;
• Vaccines and immunizations to prevent certain illnesses in infants, children and adults;
• Contraceptives for women.

Requirements & Limitations

Be sure to present your Vendor ID card containing the OptumRx billing information to get these products for $0.  Also, for any qualifying Preventive Care Medications to be covered by the plan, the following criteria must be met:

• Medication must be prescribed by a health care professional. You must get a prescription for these products from your doctor, even if the products are sold over-the-counter (OTC).
• Age- and condition-appropriate. Some products have drug rationale and requirements that must be met to qualify for coverage. Also, some products also have quantity limits based on FDA approved dosing or product packaging.
• Filled at a network pharmacy

Drugs on this list can and do change periodically. For a current list of covered Preventative Care Medications, please click the Active Plans & Non-Medicare Retirees Handouts & Forms tile towards the bottom of the page.

Specialty Medications require a Prior Authorization before they can be filled.  To determine if your specialty medication is covered, please call the OptumRx Customer Care Call Center at (855) 697-9150.

Specialty medication should be filled by the OptumRx Specialty Pharmacy.  For more information, visit specialty.optumrx.com or call (855) 427-4682.

Prescription Drug Program compounded drug guidelines are as follows:

• Compounded drugs will be covered if at least one of the ingredients is covered through the plan
• If the cost of the compounded exceeds $300, a Prior Authorization (PA) is required. If your PA request is denied, you are responsible for 100% of the cost of the medication.
• Compounded drugs must be filled through an in-network pharmacy. You can find the most current Compounding Pharmacy Locator Guide by clicking on the Active Plans & Non-Medicare Retirees Handouts & Forms tile towards the bottom of the page.
• Compounded drugs should be billed through the Prescription Drug Program billing information located on your Midwest Operating Engineers vendor ID card. If the in-network pharmacy you are filling your compounded drug at does not bill insurance, ask the pharmacy to give you a completed “Universal Claim Form for a Compounded Medication”. 
  • In this instance only, you can submit the completed Universal Claim Form for a
    Compounded Medication along with the register receipt to the Pharmacy Benefit
    Department for consideration of reimbursement.
  • This documentation can be mailed to the following address:

Attn: Pharmacy Benefit Department
6150 Joliet Rd.
Countryside, IL 60525

Please note that if your compounded drug does not meet the guidelines outlined above, it will not be covered by the Prescription Drug Program. If you choose to pay out-of-pocket, you are responsible for 100% of the cost of the medication, and no reimbursement is allowed.

Yes.  You can get your flu shot and other routine vaccines that prevent illnesses like tetanus, pneumonia and shingles.  Routine vaccines are available on most plans and can help you and your family maintain better overall health.

The OptumRx Vaccine Program handout contains a complete vaccine list along with recommended pharmacies.  You can find this handout by clicking on the Active Plans & Non-Medicare Retirees Handouts & Forms tile towards the bottom of the page.