We are proudly partnered with OptumRx. They have a team of pharmacists, care management and customer service advocates all working to make sure you get the medication you need, conveniently and cost-effectively.
The Fund Office also has a Pharmacy Benefit Department that works as a liaison between the membership and OptumRx.
If your prescription does not go through the insurance, for any reason, after you have presented your Vendor Card to the Pharmacy Staff, then call the Pharmacy Benefit Department at 708-387-8331 immediately. There is a reason that the prescription is not going through so please be sure to promptly contact us so our staff can investigate what is going on.
Claims can be re-processed at a Pharmacy within 7 days that the prescription was originally processed, and an accurate refund can be issued. The Pharmacy Benefit Department cannot issue a reimbursement for anything that was paid out-of-pocket after 7 days that the prescription was picked up.
If you have any questions regarding your pharmacy benefits, please contact OptumRx Customer Care Call Center at (855) 697-9150 or the Pharmacy Benefit Department at (708) 387-8331.
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
It is important to note that these drug lists can and do change, so it’s always good to check the OptumRx Preventive Care Medications list.
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 compound drug guidelines are as follows:
- Compound drugs will be covered if at least one of the ingredients is covered through the plan
- If the cost of the compound 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.
- Compound drugs must be filled through an in-network pharmacy. To locate an in-network compounding pharmacy, you can review the most current “Compounding Pharmacy Locator Guide”. This guide can also be found by clicking on the Active Members and Non-Medicare Retirees Handouts & Forms box at the bottom of this page.
- Compound drugs must be billed through the Prescription Drug Program billing information located on your Midwest Operating Engineers vendor ID card, without exception! If the pharmacy you are trying to fill your compound drug at does not bill insurance, it is imperative that you use the “Compounding Pharmacy Locator Guide” to find one that does. There is no reimbursement for compound drugs that were not submitted through insurance, so it is important to follow proper compound billing procedures.
If you attempt to fill a compound drug and it is denied at an in-network compounding pharmacy, it is likely that your compound drug does not meet the Prescription Drug Program compound drug guidelines.
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.
For a complete vaccine list along with recommended pharmacies, click here.