Page 7 - 2017-18 Optimas Benefits Guide
P. 7
Important Prescription Drug Information
Coverage for prescription drugs is limited to the cost of a generic equivalent medication. If you choose a brand drug when a
generic equivalent is available, you will pay the cost difference.
Prescriptions with an over-the-counter equivalent are excluded from coverage
Quantity limits do apply to certain medications
Medications found on OptumRx’s expanded preventive drug list are covered at 100% and must be illed through mail order
Medications found on the HCR preventive drug list are covered at 100% and are not required to be illed through mail
order
Certain drugs, including specialty drugs, must be illed through a designated OptumRx specialty pharmacy
Some drugs may have a prior authorization or medical necessity requirement
If you use a non-network pharmacy, you are responsible for any amount over the allowed amount
Prescription drug lists (PDLs) which include the expanded preventive, HCR preventive, specialty, prior authorization, exclusions,
medical necessity, and those with quantity limitations can be found on myuhc.com or on the ADP/WFN portal as you enroll for
beneits.
Employee Medical Premiums (Weekly/Bi-Weekly)
This chart illustrates your pre-tax contributions for each of the Optimas medical plans.
Consumer Driven Plan 1 Consumer Driven Plan 2
Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employees Earning <$35K
Employee Only $20.00 $40.00 $86.67 $13.96 $27.92 $60.50
Employee + Spouse $68.41 $136.83 $296.46 $59.22 $118.44 $256.63
Employee + Child(ren) $40.00 $80.01 $173.35 $33.36 $66.73 $144.58
Family $80.41 $160.83 $348.46 $70.34 $140.69 $304.82
Employees Earning between $35K–$50K
Employee Only $29.34 $58.67 $127.12 $17.77 $35.54 $77.00
Employee + Spouse $89.75 $179.50 $388.91 $70.34 $140.69 $304.82
Employee + Child(ren) $57.34 $114.67 $248.46 $43.10 $86.19 $186.75
Family $111.08 $222.17 $481.36 $87.03 $174.06 $377.12
Employees Earning between $50K–$75K
Employee Only $36.00 $72.00 $156.01 $22.85 $45.69 $99.00
Employee + Spouse $109.75 $219.50 $475.58 $81.47 $162.93 $353.02
Employee + Child(ren) $78.67 $157.34 $340.91 $54.22 $108.44 $234.95
Family $139.08 $278.17 $602.70 $102.32 $204.64 $443.38
Employees Earning between 75K–$100K
Employee Only $44.00 $88.01 $190.68 $25.38 $50.77 $110.00
Employee + Spouse $125.75 $251.50 $544.92 $89.81 $179.61 $389.16
Employee + Child(ren) $96.01 $192.01 $416.03 $62.56 $125.12 $271.09
Family $168.42 $336.84 $729.82 $116.22 $232.44 $503.62
Employees Earning >$100K
Employee Only $58.67 $117.34 $254.24 $34.27 $68.54 $148.50
Employee + Spouse $161.75 $323.51 $700.93 $109.27 $218.54 $473.50
Employee + Child(ren) $128.01 $256.02 $554.71 $80.63 $161.27 $349.41
Family $216.42 $432.85 $937.84 $144.03 $288.05 $624.11
Optimas 7
Coverage for prescription drugs is limited to the cost of a generic equivalent medication. If you choose a brand drug when a
generic equivalent is available, you will pay the cost difference.
Prescriptions with an over-the-counter equivalent are excluded from coverage
Quantity limits do apply to certain medications
Medications found on OptumRx’s expanded preventive drug list are covered at 100% and must be illed through mail order
Medications found on the HCR preventive drug list are covered at 100% and are not required to be illed through mail
order
Certain drugs, including specialty drugs, must be illed through a designated OptumRx specialty pharmacy
Some drugs may have a prior authorization or medical necessity requirement
If you use a non-network pharmacy, you are responsible for any amount over the allowed amount
Prescription drug lists (PDLs) which include the expanded preventive, HCR preventive, specialty, prior authorization, exclusions,
medical necessity, and those with quantity limitations can be found on myuhc.com or on the ADP/WFN portal as you enroll for
beneits.
Employee Medical Premiums (Weekly/Bi-Weekly)
This chart illustrates your pre-tax contributions for each of the Optimas medical plans.
Consumer Driven Plan 1 Consumer Driven Plan 2
Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly
Employees Earning <$35K
Employee Only $20.00 $40.00 $86.67 $13.96 $27.92 $60.50
Employee + Spouse $68.41 $136.83 $296.46 $59.22 $118.44 $256.63
Employee + Child(ren) $40.00 $80.01 $173.35 $33.36 $66.73 $144.58
Family $80.41 $160.83 $348.46 $70.34 $140.69 $304.82
Employees Earning between $35K–$50K
Employee Only $29.34 $58.67 $127.12 $17.77 $35.54 $77.00
Employee + Spouse $89.75 $179.50 $388.91 $70.34 $140.69 $304.82
Employee + Child(ren) $57.34 $114.67 $248.46 $43.10 $86.19 $186.75
Family $111.08 $222.17 $481.36 $87.03 $174.06 $377.12
Employees Earning between $50K–$75K
Employee Only $36.00 $72.00 $156.01 $22.85 $45.69 $99.00
Employee + Spouse $109.75 $219.50 $475.58 $81.47 $162.93 $353.02
Employee + Child(ren) $78.67 $157.34 $340.91 $54.22 $108.44 $234.95
Family $139.08 $278.17 $602.70 $102.32 $204.64 $443.38
Employees Earning between 75K–$100K
Employee Only $44.00 $88.01 $190.68 $25.38 $50.77 $110.00
Employee + Spouse $125.75 $251.50 $544.92 $89.81 $179.61 $389.16
Employee + Child(ren) $96.01 $192.01 $416.03 $62.56 $125.12 $271.09
Family $168.42 $336.84 $729.82 $116.22 $232.44 $503.62
Employees Earning >$100K
Employee Only $58.67 $117.34 $254.24 $34.27 $68.54 $148.50
Employee + Spouse $161.75 $323.51 $700.93 $109.27 $218.54 $473.50
Employee + Child(ren) $128.01 $256.02 $554.71 $80.63 $161.27 $349.41
Family $216.42 $432.85 $937.84 $144.03 $288.05 $624.11
Optimas 7
