Pharmacy Benefits

The plans use OptumRx®’s Value 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 Kaiser HRA plan, you must fill your prescriptions at a Kaiser pharmacy for them to be covered.

If you’re enrolled in an HRA plan, you cannot use your HRA to pay for your prescription drugs, so you’ll need to pay out of your pocket for these expenses. If you’re enrolled in the Aetna Choice HSA, you can use your HSA to pay for prescription drugs.

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 the Aetna Basic HRA, Aetna Select HRA or Aetna Choice HSA. 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. Alight (Formerly Compass) can help you sign up for mail-order savings.

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In Network Benefits

Aetna Basic PPO Aetna Select HRA Aetna Choice HSA Kaiser HRA
In Network Benefits Only1
Preventive Drug List1
$0 copay1 $0 copay $0 copay1 $0 (based on ACA required coverage)
Generic
Retail2: $14 copay
Mail-order3: $35 copay
Retail2: $7 copay
Mail-order3: $18 copay
Before you meet deductible: You pay full cost of drug. After you meet deductible: You pay 20% Retail1: $10 copay for up to a 30-day supply
Mail-order2: $20 copay for up to a 100-day supply
Preferred Brand
Retail2: 25% of the cost ($50 minimum; $130 maximum)
Mail-order3: $125 copay
Retail2: 25% of the cost ($30 minimum; $120 maximum)
Mail-order3: $75 copay
Before you meet deductible: You pay full cost of drug
After you meet deductible: You pay 20%
Retail1: $30 copay for up to a 30-day supply
Mail-order2: $60 copay for up to a 100-day supply
Non-Preferred Brand
80% coinsurance4 80% coinsurance Before you meet deductible: You pay full cost of drug. After you meet deductible: You pay 80% N/A
Specialty Tier5
Generic: Retail2:
$14 copay
Preferred brand:Retail2: 25% of the cost ($50 minimum; $130 maximum)Non-Preferred brand:
50% coinsurance ($350 maximum)
Generic:
Retail2: $7 copay
Preferred brand:
Retail2: 25% of the cost ($30 minimum; $120 maximum)
Non-Preferred brand:
50% coinsurance ($350 maximum)
Generic:
Before you meet deductible: You pay full cost of drug
After you meet deductible: You pay 20% ($200 maximum)
Preferred brand:
Before you meet deductible: You pay full cost of drug
After you meet deductible: You pay 20% ($250 maximum)
Non-Preferred brand:
Before you meet deductible: You pay full cost of drug
After you meet deductible: You pay 50% ($350 maximum)
$0, no deductible
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
$2,050 $1,950 Included in medical out-of-pocket maximum Included in medical out-of-pocket maximum
Family
$4,100 $3,900 Included in medical out-of-pocket maximum Included in medical out-of-pocket maximum
1. Generic and Insulin only.
2. Up to 30-day supply.
3. Up to 90-day supply. Also available at your local CVS pharmacy, the same as through mail order.
4. Does not apply to out-of-pocket-maximum
5. Specialty applies 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

OptumRx is an affiliate of UnitedHealthcare Insurance Company