The Consumer Driven Option pharmacy benefit is provided by OptumRx, a UnitedHealth Group company offering high quality pharmacy benefit services. The OptumRx network includes more than 64,000 retail pharmacies, including all large national chains, many local community pharmacies and the OptumRx Home Delivery.
The Consumer Driven Health Plan covers prescription drugs in the same way it covers other healthcare expenses:
A Personal Care Account
We provide you with a Personal Care Account (PCA) in which $1,200 (Self Only) or $2,400 (Self Plus One and Self and Family) is available annually to cover your eligible expenses. You choose how you spend these dollars, and your costs are covered at 100%.
If you order prescription medication when you have benefit dollars available in your Personal Care Account, you pay nothing. Your prescription drug is covered at 100%. By using the mail order service or a network pharmacy, you receive a discounted price. Your PCA account is charged the discounted cost of the prescription medication, which is then subtracted from the PCA.
Remaining dollars roll over
Any benefit dollars remaining in the PCA at year-end are rolled over and added to the PCA for the next year. This allows you to build savings for future healthcare needs, including prescription drugs.
What happens if you go over?
If your expenses exceed the $1,200/$2,400 in your PCA, you pay the next $1,000 for Self or $2,000 for Self Plus One and Self and Family. This is called your net deductible.
Then, traditional health care begins
If you have expenses over $2,200 for Self Only or $4,400 (PCA + net deductible for Self Only/Self and Family), then traditional health coverage begins. You pay 25% of the discounted cost of prescriptions – $10 minimum for network retail pharmacy or $15 minimum if you use the mail order pharmacy. There is a maximum of $200 coinsurance per prescription for network retail and $600 coinsurance per prescription for mail order.
If you do not use your member identification card at a network pharmacy or, if you use a pharmacy outside of the network, the Plan provides no benefit and you must pay the full cost.
Non-network retail drugs are covered under the in-network benefit only if necessary and prescribed for sudden illness while traveling outside of the United States, including Puerto Rico.