SHBP Transition to Optum Rx

OptumRx Transition Documents

Optum RX takes over from Express Scripts on December 23 and January 1; New OptumRx Prescription Cards Mailed

The takeover of prescription drug services for the State Health Benefits Plan by OptumRx from Express Scripts is happening over the next several weeks.

Prescription drug services for the State Health Benefits Plan—active employees and retirees—will change to OptumRx.

For most state employees who are on the biweekly payroll, the effective date for OptumRx coverage is December 23, 2017. 

For state employees on monthly payroll—primarily at state colleges and universities— all local government, all school district Employees, and all retirees— the effective date will be January 1, 2018.

Members should have already received communication from both the Division of Pensions and Benefits and OptumRx about the change in the prescription vendor and a welcome packet from OptumRx. This packet will include the new OptumRx prescription drug card; the packets should be received by members by December 15.

If members haven’t received a card by December 15, they can call OptumRx at 1-844-368-8740 for active employees and early retiree members and 1-844-368-8765 for Medicare retiree members.

No Change in Drug Benefit, Co-Pays for 2018

There is no change to the benefits provided by our prescription drug plan for 2018.  Co-pays remain the same as Plan Year 2017.

OptumRx will honor the same pharmacy network— you can still use your favorite pharmacy.

The awarding of the prescription drug contract to OptumRx brought significant savings and was a major factor in the 0% premium increases for 2018.

Changes Due to the New Administer of Prescription Benefits

There are changes in the manner that OptumRx will administer our prescription plan.

The biggest change will be because OptumRx has a slightly different formulary than Express Scripts, though they overlap for around 85% of formulary drugs for active employees. Fortunately, the category of drugs most used on the formulary, diabetes medicines and equipment, are nearly identical on the two formularies.

(Information on the new OptumRx formularies is attached.)

Members currently receiving medications not on the OptumRx formulary should have received disruption letter(s) indicating that they may have to change a medication. Members should have also received letters indicating that they will need to have their doctor extend the prior authorization they currently have for the drug they are receiving.

If a member believes that there is a bona fide medical reason to remain with the drug they have been using, they should consult their doctor and seek the doctor’s assistance to appeal the decision of OptumRx. The number to use to start an appeal is 1-888-368-8740.

Choosing Medication

When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions.

Medications are then listed alphabetically. If your medication is not listed in this document, please visit or call toll free at 1-888-368-8740.

Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

“What if I don’t agree with a decision about an excluded medication?”

You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling toll free at 1-888-368-8740.

Generic Drugs

As you know our prescription plan requires the use of generic drugs when they are available in order to avoid members paying an excessive amount for a brand drug.

However, we have now found out that the Express Scripts mail-order pharmacy frequently filled prescriptions for brand-name drugs even though the prescription was either written by a doctor for a generic or allowed generic substitution for a brand-name drug. Members who this situation relates to automatically received letters indicating that they have not gotten a generic drug when it was available.

The largest number of substitutions of brand-name drugs for generics was for Adderall and Concerta were substituted for their generic equivalents.

OptumRx will be sending an additional letter to members explaining this situation in greater detail. This should alleviate the confusion that Express Scripts actions of substituting brand-name drugs for generics has caused.

Under Express Scripts many members received exceptions to the formulary. All prior authorizations and exceptions granted were transferred to Optum RX and should be honored unless the prior authorization time limit has expired.

Non-FDA Approved Medications
The Division of Pensions and Benefits has identified the utilization of the following medications that would not be covered under OptumRx as they are not currently FDA approved.
The manufacturer of Klor-Con recently submitted for FDA approval of their powder and the FDA approved their request this week.  We’re looking into the timing of when that medication will be removed from the non-FDA medication exclusion list we will follow up with confirmation as soon as we hear back.  Letters were sent to 4 members informing them that Klor-Con would not be covered effective 1/1/18.  As soon as we have confirmation that the list will be updated to allow for coverage we can request outbound calls to those members to let them know that their medication should now be covered due to the recent FDA approval.

Prescription Drug Coverage for Medicare Retirees

We don’t have any information yet on the number of Medicare retirees who have or will receive disruption letters as there are some differences between the Express Scripts and OptumRx formularies.  Similar to active members and early retirees, we expect a low percentage of prescriptions and members to be affected. There is no list of excluded drugs for Medicare retirees; however, as with the active and early retiree program some drugs require prior authorization, have quantity limits, or may be subject to a step therapy program.

As with active members and early retirees, if a retiree believes that there is a bona fide medical reason to remain with the drug they have been using, they should consult their doctor and seek the doctor’s assistance to appeal the decision of OptumRx. The number to use to start an appeal is 1-844-368-8765.

Medicare regulations require that the member is eligible for a transition fill while they are in the process of having their prior authorizations or appeal processed.