Pharmacy Benefits

The plans use OptumRx’s Premium Standard Formulary, a list of preferred drugs that cost you less.

If your doctor writes you a prescription, make sure it’s on the formulary. If it’s not, ask your doctor whether another drug on the formulary will work for you.

If you’re enrolled in an Aetna plan, you have the option of filling your prescriptions at a retail location or using home delivery for maintenance medications.

If you’re enrolled in the Aetna Choice HSA, you can use your HSA to pay for prescription drugs.

If you’re enrolled in the Kaiser HRA plan, you must fill your prescriptions at a Kaiser pharmacy for them to be covered. You cannot use your HRA to pay for prescription drugs, so you’ll need to pay out of your pocket for these expenses.

Go to a Retail Pharmacy

Retail pharmacies are best for filling medications you’ll use for 30 days or less. You can get your medication and begin using it almost immediately.

Get a 90-Day Home Delivery Prescription

Home Delivery prescriptions are best for filling medications you’ll take for 90 days or more. Make sure you ask your doctor to write the prescription for 90 days. He/she may be able to upload the prescription directly to the prescription drug provider. If not, you must complete a home delivery service form (on OptumRx’s website) and send in your written prescription.

This option can take up to two weeks to receive your medication. If you need medication immediately, ask your doctor for a 30-day prescription you can fill at your local pharmacy. Or, you can also receive a 90-day supply at your local CVS pharmacy, and you won’t have to wait to receive it.

Maintenance Medications

If you take maintenance medications (prescriptions you need on a regular basis for an ongoing condition, such as high blood pressure), using home delivery is mandatory if you enroll in an Aetna plan. You will be allowed two 30-day fills at a pharmacy or retail location. After that, you’re required to get a 90-day supply through mail order or at a local CVS pharmacy. Maintenance medications on the preventive drug list are available for $0 copay with no deductible.

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In-Network Benefits

Aetna Choice HSA Aetna Basic PPO Aetna Enhanced PPO Kaiser HRA
In-Network Benefits Only
Preventive Drug List1
$0 copay $0 copay $0 copay $0 (based on ACA required coverage)
Generic
Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 20% Retail2: $14 copay
Mail-order3: $35 copay		 Retail2: $10 copay
Mail-order3: $20 copay		 Retail2: $10 copay
Mail-order3: $20 copay
Preferred Brand
Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 20% Retail2: 25% ($50 min; $130 max)
Mail-order3: $125 copay		 Retail2: $35 copay
Mail-order3: $70 copay		 Retail2: $30 copay
Mail-order3: $60 copay
Non-Preferred Brand4
Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay 50% ($100 min; $250 max) 50% after deductible ($100 min; $250 max) 50% after deductible ($100 min; $250 max) Retail2: $30 copay
Mail-order3: $60 copay
Specialty Pharmacy5
Before you meet deductible, you pay full cost of drug. After you meet deductible, you pay:
Generic: 20% ($200 max)
Preferred brand: 20% ($250 max)
Non-Preferred brand: 50% ($350 max)		 Generic: $14 copay
Preferred brand: 25% ($50 min; $130 max)
Non-Preferred brand:
50% after deductible ($350 max)		 Generic: $10 copay
Preferred brand: $35 copay
Non-Preferred brand:
50% after deductible ($350 max)		 $30 copay in most cases
Out-of-pocket maximum (If you reach this limit, Michaels pays 100% of all remaining eligible prescription drug costs for the rest of the plan year).
Individual
Included in medical out-of-pocket max $2,050 Included in medical out-of-pocket max Included in medical out-of-pocket max
Family
Included in medical out-of-pocket max $4,100 Included in medical out-of-pocket maximum Included in medical out-of-pocket max
1. Generic and insulin only.
2. Up to 30-day supply.
3. With Aetna plans, up to 90-day supply; also available at your local CVS pharmacy, the same as through mail order. The Kaiser HRA allows up to a 100-day supply.
4. Non-preferred brand drug costs don’t apply to the out-of-pocket-maximum.
5. Up to a 30-day supply. Specialty drug costs apply to out-of-pocket-maximum.

OptumRx Diabetes Management Program

This free program is available to eligible Full-Time Team Members enrolled in an Aetna medical plan. OptumRx will send invite packets based on medical claims and diabetes diagnoses.

The program for high-risk diabetic members helps control blood sugar, A1C levels and co-morbidities to achieve positive results and identify level of risk for disease progression and complications. It includes is one-on-one counseling and education.

Provider