Health plan enrollment through Syracuse University provides you with prescription drug coverage through Optum Rx, with member cost-sharing summarized below:
| Prescription Drug Plan | SUBlue and SUOrange | SUPro |
|---|---|---|
| Annual Deductible | No deductible | No deductible |
| Annual Out-of-Pocket Maximum | $2,000 single/$4,000 family | $2,000 single/$4,000 family |
| Retail Pharmacy: Your Cost (Up to a 90-day Supply) | ||
| Tier 1 | 20% coinsurance* | 15% coinsurance* |
| Tier 2 | 25% coinsurance | 25% coinsurance |
| Tier 3 | 45% coinsurance | 40% coinsurance |
| Home Delivery: Your Cost (Up to a 90-Day Supply) | ||
| Tier 1 | $20 copayment* | Lesser of $15 or 15% coinsurance* |
| Tier 2 | $50 copayment | Lesser of $45 or 25% coinsurance |
| Tier 3 | $90 copayment | Lesser of $90 or 40% coinsurance |
| Specialty Home Delivery: Your Cost (Up To A 30-Day Supply) | ||
| Specialty Medications | Same as Home Delivery, except up to a 30-day supply | |
| Infertility Medications | Retail, mail order and specialty member cost-sharing with a $20,000 lifetime maximum | |
*Certain preventive prescription drugs are available at $0 copay, restrictions may apply; contact Optum Rx for details.
Coverage Details
Your cost for prescription drugs generally depends on two main factors: where you fill your script, either through a retail pharmacy or home delivery, and the tier your medication is placed on within the formulary. In addition, utilization management programs may require additional information from your provider to be approved for coverage.
What is a formulary?
A formulary is a list of preferred medications selected by Optum Rx based on safety, effectiveness and cost. Medications are generally divided into three tiers, unless considered a specialty drug. A drug is generally not covered if it is excluded from the formulary. Talk to your doctor about covered alternatives to avoid paying full price. Your provider can also request a prior authorization review with Optum Rx.
Why does the formulary change?
Formularies are updated regularly as new drugs become available and generics replace brand name medications. These updates may affect your out-of-pocket costs. You can check the most up-to-date formulary by logging into Optum Rx’s secure member website.
Understanding Generic Medications
Generic drugs contain the same active ingredients as brand-name drugs and meet FDA standards for safety, quality and effectiveness. They are typically more affordable. If a generic is available and you or your doctor choose the brand-name drug (by selecting “Dispense as Written”), you will pay the generic copay plus the difference between the brand name drug cost and the generic drug cost.
Member Services
There are various ways to access your account to get information about your claims and coverage:
- Call Optum Rx member services at 866.854.2945 (TTY: 711) – available to assist you 24/7.
- Register online for secure access. Dependents 18 and older must create their own online account, but may give you permission to view their claim information.
- Download the Optum Rx mobile app to check prescription costs, view your ID card, find pharmacies, set medication reminders, track history, and reorder home deliveries. Use the Optum Rx Digital Action Guide [PDF] as a guide to get set-up.
Pharmacy Network: Retail, Home Delivery and Specialty
Most national retail pharmacies participate with the Optum Rx network. Find participating locations and use Optum Rx’s pricing tool by logging into Optum Rx, by using the mobile app, or by calling Optum Rx Member Services at 866.854.2945 (TTY: 711). This will help you determine which method, retail or home delivery, is most convenient and cost-effective for each drug. Remember, you can fill a 90-day supply at a retail pharmacy or through home delivery, where home delivery cost-sharing applies, potentially lowering costs.
Certain medications that treat complex medical conditions or require special monitoring or handling, may be considered specialty drugs and must be dispensed through the Optum Specialty Pharmacy. Contact Optum Rx at 844.265.1761 (TTY: 711) to set up your account and coordinate the delivery of your medication.
Member Contributions
The University covers a significant portion of the cost of your health coverage, including prescriptions, with the remaining cost shared by you through payroll deduction. Review your contributions by visiting the Member Contributions section on the health plan page.
Should you have any questions, or require accommodations to access any information on this webpage, please contact HR Shared Services at 315.443.4042.
Helpful Links
- Benefits Eligibility Policy
- Optum Rx Member Website
- Optum Rx Digital Action Guide [PDF]
- Optum Rx Home Delivery Prescription Order Form [PDF]
Every effort has been made to ensure that the information contained within this website is accurate. However, benefits are governed by legal documents (which, in certain circumstances, may include insurance contracts). If there is any difference between the information in this website and the official documents, the official documents will control. As is the case with all of Syracuse University’s employee benefit plans, the University reserves the right to modify or terminate these benefits at any time.