Prescription drug coverage is included with your health plan, administered through Optum Rx. Here’s what you need to know about costs, your pharmacy options, and how to make the most of your coverage.
Your Member Cost-Sharing
| 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 Optum Rx’s list of preferred medications, selected based on safety, effectiveness, and cost. Drugs are typically placed into one of three tiers — where a medication lands determines your cost. If a drug isn’t on the formulary, it’s generally not covered. Talk to your doctor about covered alternatives, or ask them to submit a prior authorization request to Optum Rx.
Why does the formulary change?
Formularies are updated regularly as new drugs come to market and generics replace brand-name medications. These changes can affect what you pay, so it’s worth checking the current formulary by logging into your Optum Rx account.
Understanding Generic Medications
Generics contain the same active ingredients as brand-name drugs and meet the same FDA standards for safety, quality, and effectiveness — at a lower cost. If a generic is available and you or your doctor request the brand-name version (“Dispense as Written”), you’ll pay the generic copay plus the cost difference between the brand-name and generic drug.
Member Services
There are several easy ways to access your account, check coverage, and manage your medications:
- Call: Optum Rx Member Services at 866.854.2945 (TTY: 711) — available 24/7
- Online: Register at OptumRx.com to view claims, check drug costs, and manage your coverage. Dependents 18 and older must create their own account but can grant you permission to view their information.
- Mobile App: Download the Optum Rx app to check prescription costs, view your ID card, find pharmacies, set medication reminders, and reorder home deliveries. Use the Optum Rx Digital Action Guide (PDF) to get started.
Pharmacy Network: Retail, Home Delivery and Specialty
Most national retail pharmacies participate in the Optum Rx network. You can fill up to a 90-day supply at retail or through home delivery — and home delivery often means lower out-of-pocket costs. Use OptumRx.com, the mobile app, or call 866.854.2945 (TTY: 711) to find participating pharmacies and compare pricing before you fill.
Some medications that treat complex conditions or require special handling must be filled through the Optum Specialty Pharmacy. Call 844.265.1761 (TTY: 711) to set up your account and arrange delivery.
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 Contributions section on the health plan page.
If you have any questions or need an accommodation to access 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]
- HIPAA Notice of Privacy Practices
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.