Page 7 - 2018-19 Optimas Enrollment
P. 7
Optimas
Important Prescription Drug Information
Prescriptions with an over-the-counter equivalent Certain drugs, including specialty drugs, must be
are excluded from coverage filled through a designated OptumRx specialty
Quantity limits do apply to certain medications pharmacy
Medications found on OptumRx’s standard Some drugs may have a prior authorization or
preventive drug list are covered at 100% medical necessity requirement
Medications found on the HCR preventive drug list If you use a non-network pharmacy, you are
are covered at 100% responsible for any amount over the allowed
amount
Prescription drug lists (PDLs) which include the standard preventive, HCR preventive, specialty, prior
authorization, exclusions, medical necessity, and those with quantity limitations can be found on umr.com
or on the Ultipro 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 $37.31 $74.62 $161.67 $31.27 $62.54 $135.50
Employee + Spouse $85.72 $171.44 $371.46 $76.53 $153.06 $331.63
Employee + Child(ren) $57.31 $114.63 $248.36 $50.67 $101.34 $219.58
Family $97.72 $195.44 $423.46 $87.65 $175.30 $379.82
Employees Earning between $35K–$50K
Employee Only $46.64 $93.29 $202.12 $35.08 $70.15 $152.00
Employee + Spouse $107.06 $214.11 $463.91 $87.65 $175.30 $379.82
Employee + Child(ren) $74.64 $149.29 $323.46 $60.40 $120.81 $261.75
Family $128.39 $256.78 $556.36 $104.34 $208.67 $452.12
Employees Earning between $50K–$75K
Employee Only $53.31 $106.62 $231.01 $40.15 $80.31 $174.00
Employee + Spouse $127.06 $254.11 $550.58 $98.77 $197.55 $428.02
Employee + Child(ren) $95.98 $191.96 $415.91 $71.53 $143.05 $309.95
Family $156.39 $312.78 $677.70 $119.63 $239.25 $518.38
Employees Earning between $75K–$100K
Employee Only $61.31 $122.62 $265.68 $42.69 $85.38 $185.00
Employee + Spouse $143.06 $286.12 $619.92 $107.11 $214.23 $464.16
Employee + Child(ren) $113.31 $226.63 $491.03 $79.87 $159.73 $346.09
Family $185.73 $371.46 $804.82 $133.53 $267.06 $578.62
Employees Earning >$100K
Employee Only $75.98 $151.96 $329.24 $51.58 $103.15 $223.50
Employee + Spouse $179.06 $358.12 $775.93 $126.58 $253.15 $548.50
Employee + Child(ren) $145.32 $290.64 $629.71 $97.94 $195.88 $424.41
Family $233.73 $467.46 $1,012.84 $161.33 $322.67 $699.11
7
Important Prescription Drug Information
Prescriptions with an over-the-counter equivalent Certain drugs, including specialty drugs, must be
are excluded from coverage filled through a designated OptumRx specialty
Quantity limits do apply to certain medications pharmacy
Medications found on OptumRx’s standard Some drugs may have a prior authorization or
preventive drug list are covered at 100% medical necessity requirement
Medications found on the HCR preventive drug list If you use a non-network pharmacy, you are
are covered at 100% responsible for any amount over the allowed
amount
Prescription drug lists (PDLs) which include the standard preventive, HCR preventive, specialty, prior
authorization, exclusions, medical necessity, and those with quantity limitations can be found on umr.com
or on the Ultipro 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 $37.31 $74.62 $161.67 $31.27 $62.54 $135.50
Employee + Spouse $85.72 $171.44 $371.46 $76.53 $153.06 $331.63
Employee + Child(ren) $57.31 $114.63 $248.36 $50.67 $101.34 $219.58
Family $97.72 $195.44 $423.46 $87.65 $175.30 $379.82
Employees Earning between $35K–$50K
Employee Only $46.64 $93.29 $202.12 $35.08 $70.15 $152.00
Employee + Spouse $107.06 $214.11 $463.91 $87.65 $175.30 $379.82
Employee + Child(ren) $74.64 $149.29 $323.46 $60.40 $120.81 $261.75
Family $128.39 $256.78 $556.36 $104.34 $208.67 $452.12
Employees Earning between $50K–$75K
Employee Only $53.31 $106.62 $231.01 $40.15 $80.31 $174.00
Employee + Spouse $127.06 $254.11 $550.58 $98.77 $197.55 $428.02
Employee + Child(ren) $95.98 $191.96 $415.91 $71.53 $143.05 $309.95
Family $156.39 $312.78 $677.70 $119.63 $239.25 $518.38
Employees Earning between $75K–$100K
Employee Only $61.31 $122.62 $265.68 $42.69 $85.38 $185.00
Employee + Spouse $143.06 $286.12 $619.92 $107.11 $214.23 $464.16
Employee + Child(ren) $113.31 $226.63 $491.03 $79.87 $159.73 $346.09
Family $185.73 $371.46 $804.82 $133.53 $267.06 $578.62
Employees Earning >$100K
Employee Only $75.98 $151.96 $329.24 $51.58 $103.15 $223.50
Employee + Spouse $179.06 $358.12 $775.93 $126.58 $253.15 $548.50
Employee + Child(ren) $145.32 $290.64 $629.71 $97.94 $195.88 $424.41
Family $233.73 $467.46 $1,012.84 $161.33 $322.67 $699.11
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