Prescription Drug Coverage

If you are an eligible participant under an Active Plan or an eligible non-Medicare retiree, spouse or dependent, we have partnered with OptumRx for all of your pharmaceutical needs.

Filling a Prescription

  • Short-Term Medication- These prescriptions can be filled at any in-network pharmacy (CVS, Target, Walgreens etc.). To locate an in-network pharmacy closest to you, register on www.optumrx.com and access the Pharmacy Locator icon, your personalize Medicine Cabinet, OptumRx Home Delivery Pharmacy, and much more!
    • You may receive up to two 30-day supplies of a short-term medication, but if you seek a third refill of that medication it is no longer considered short-term. When seeking a third refill it is now considered a long-term medication (maintenance medication), and you must transition to a CVS retail pharmacy or the OptumRx Home Delivery pharmacy to obtain a 90-day supply. Alternately, you can choose to stay at your current pharmacy for that refill; however, for any future refills you will be responsible to pay 100% of the cost of the medication. Please note, if you choose to pay the 100% of the cost no reimbursement will be allowed.
  • Long-Term Medication (Maintenance Medication)- These prescriptions can be filled at any CVS retail pharmacy:
    • These medications can be filled as 90-day supplies only.
  • Long-Term medication can also be filled through the OptumRx Home Delivery pharmacy:
    • Mention to your physician that you would like to use the OptumRx Home Delivery pharmacy and they can call, fax or electronically submit your prescription to them for processing.
    • You can contact their Customer Care Call Center at (855) 697-9150 (855-MYRX150) to answer any questions you may have, update your form of payment, track an order, update your address, and much more.

4- Tier Program

Our program offers a convenient 4-tier structure to meet all your medication needs. The 4-tiers are as follows:

  • Generic Medication (Tier 1)
  • Preferred Brand Name Medication (Tier 2)
  • Non-preferred Brand Name Medication (Tier 3)
  • Specialty Medication (Tier 4)

    OptumRx’s Select Formulary List

    The OptumRx Select Formulary list is a guide within select therapeutic categories for Plan members and health care providers. Ask your physician to consider prescribing generic medication as a first line option, when medically appropriate, from the OptumRx Select Formulary list. Generic medications are typically a lower cost to the plan, and these savings are immediately passed directly to the membership. If there is no generic available, there may be a preferred brand name medication listed. Click here for the OptumRx Select Formulary list  effective January 1, 2021. Be sure to mention to your provider that your plan uses the OptumRx Select Formulary for your prescription drug coverage.

    Specialty Medication

    Specialty Medications require a Prior Authorization before they can be filled. For additional information regarding Specialty Medication and the Prior Authorization process, please contact the Pharmacy Benefit Department at (708) 387-8331.

    Limitations/Exceptions- Dispense As Written (DAW) Penalty

    When available, generic medications will be substituted for all brand name medications. If a Participant requests a brand name medication, or if the prescribing physician indicates “no substitutions”, when a generic equivalent is available, the Participant will be required to pay the brand name copay plus the difference in cost between the brand name medication and its generic equivalent unless proven medically necessary through the appeals process.

    Prescription Copayments

    Each time you obtain a medication there is a copay due based on the plan you are enrolled in.  The chart below is a break down of the copay structure for Short-Term and Long-Term medications by plan.

    Prescription Processing Information

    Please be sure to present your vendor card to your local pharmacist when dropping or picking up a prescription. The “Pharmacy Benefit” tab of this card contains all the information needed to bill your pharmacy claims properly.

    Processing a Prescription Through the Prescription Drug Program

    If your prescription does NOT go through the insurance, for any reason, after you have presented your Vendor Card to the Pharmacy Staff, then call the Pharmacy Benefit Department at 708-387-8331 IMMEDIATELY. There is a reason that the prescription is not going through so please be sure to promptly contact us so our staff can investigate what is going on. Claims can be re-processed at a Pharmacy within 7 days that the prescription was originally processed, and an accurate refund can be issued. The Pharmacy Benefit Department cannot issue a reimbursement for anything that was paid out-of-pocket after 7 days that the prescription was picked up, and there is no reimbursement through the Family Supplemental Benefit (FSB).

    Retiree Benefits and Medicare Prescription Drug Benefits (Part D)

    If you enroll with Medicare for Medicare Prescription Drug Coverage, you will lose prescription drug coverage through the Midwest Operating Engineers Welfare Fund. Enrolling in Medicare Part D will not affect your other Fund health care benefits.

    For more information click on the Notice of Credible Coverage below:

    If you have any questions regarding the Prescription Drug Program please contact the Pharmacy Benefit Department at (708) 387-8331.