RxBenefits/OptumRx
Helpful Flyers
About RxBenefits
Prescription benefits are managed by OptumRx and optimized by RxBenefits. RxBenefits should always be your first point of contact with any questions or concerns related to your prescription benefits. Through RxBenefits, you can:
- View up to 18 months of claims history
- View, download, and email copies of ID cards
- Access your account across multiple devices
- Manage communication preferences
- View your pharmacy benefits coverage
About OptumRx
Through OptumRx, you can:
- Manage your mail order prescriptions
- Locate a pharmacy
- Understand your prescriptions
- Find pricing for brand and generics
- Track and manage prior authorization
Frequently Asked Questions
Who is RxBenefits?
Birmingham, AL-based RxBenefits is the industry’s first and only pharmacy benefits optimizer (PBO), dedicated to helping clients contain rising pharmacy costs while ensuring employees have access to affordable, high-quality prescription medications. Our team of more than 1,000 multidisciplinary experts are dedicated to improving your safety, lowering overall drug costs, and helping you make the most of your prescription drug coverage.
How do I use my pharmacy benefits?
Your pharmacy benefits are a component of your company’s insurance coverage plan and are designed to help you conveniently access your prescriptions at the best cost. Your pharmacy benefits give you access to a large retail pharmacy network that includes thousands of pharmacies throughout the U.S. That means you have convenient
access to your prescriptions wherever you are – at home, at work, or even on vacation. Simply present your benefits ID card and prescription at a retail pharmacy in your plan’s network. The pharmacist can use your prescription and member information to determine whether the medication you have been prescribed is covered by your plan, as well as your copayment or coinsurance.
Your Prescription Benefits Coverage (PBC) also has an overview of your plan benefits, including drug coverage, and other features important to you and your family. You can access your PBC from the My RxBenefits member portal.
You’ll get the most from your benefits by using a participating pharmacy. For a list of participating pharmacies, access your pharmacy benefits manager’s (PBM’s) website for more information. You can find a link to your PBM’s website on the MyRxBenefits member portal at Member.RxBenefits.com.
Note: If you choose a out-of-network pharmacy, you’ll pay the full cost of your prescription upfront. Then, you’ll need to submit a claim to your PBM for reimbursement. You can do this on your PBM’s website, which you can access through a link in your MyRxBenefits member portal.
How do I access the My RxBenefits member portal?
The MyRxBenefits member portal gives you 24/7 online access to your account information, ID card, and prescription details. You can also chat with our Member Services team to address any questions. Register for the portal by visiting RxBenefits.com and clicking on “Member Portal.”
What is a drug list/formulary?
All prescription benefits plans, including yours, use a “formulary” that may also be referred to as a drug list. The formulary/drug list contains brand-name and generic medications covered by your plan. All medications on the
formulary have been approved by the U.S. Food & Drug Administration (FDA) and have been reviewed and recommended by your plan’s Pharmacy & Therapeutics (P&T) Committee. The P&T Committee is an independent group of practicing doctors, pharmacists, and other healthcare professionals responsible for the research and decisions surrounding the drug list based on various factors, including their safety and effectiveness.
If your healthcare provider prescribes a medication that is not on the drug list/formulary, it will not be covered, and you will be responsible for the full cost of the medication. If your healthcare provider prescribes a non-covered
medicine, talk with them about switching to a covered alternative.
You can confirm whether a particular medication is covered under your formulary/drug list on the MyRxBenefits member portal, by chatting with Member Services, or calling the Member Services number on the back of your ID card. You can also refer to your Prescription Benefit Coverage (PBC) for coverage limitations and exclusions.
What is a prior authorization?
Certain prescription drugs may require a prior authorization (PA) review before you can fill the prescription under your insurance coverage. This is to ensure therapy is safe, appropriate, and cost-effi cient. When a medication requires a PA, your healthcare provider will need to submit a request along with supporting documentation which could include chart notes and lab work. A clinician will review these to ensure the medication is being prescribed in accordance with FDA approval criteria and clinical best practices, and that it is covered by your plan. If you use home delivery, your prescriber must obtain a PA before you can fill your prescription.
We never want you to go without appropriate medication to treat your condition. If you are having trouble filling a prescription because it requires a PA, please contact Member Services via the MyRxBenefits member portal or by calling the number on the back of your ID card. We will assist you and your healthcare provider in getting the PA processed promptly.
What is the difference between generic and brand medications? How does it affect my benefits?
Generic medications are regulated by the FDA and must be therapeutically equivalent to the brand-name drugs. They must have the same active ingredients, dosage form, strength, route of administration, and intended use.
A generic drug is introduced to the market only after the patent on its brand-name counterpart has expired. Once available, multiple manufacturers can produce the generic version, which increases market competition. As a result, generic drug manufacturers typically price their products lower than brand-name versions to remain competitive in the market.
Your healthcare provider and pharmacist are the best sources of information about generic medications. Simply ask
one of them if your prescription can be filled with an equivalent generic medication. If a generic is available but you
choose the brand-name version instead, you may be responsible for up to the full cost of the medication.
Can my prescription be switched to a drug with a lower copayment?
If your prescriber prescribes a brand-name drug, you can ask them about switching to a lower-cost generic. You can also select lower-cost options from your PBM’s website, where you manage your current prescriptions, along with information you can use to discuss switching your prescription with your prescriber.
How do I order medications using home delivery?
With home delivery you can safely and conveniently have your prescriptions delivered to your home, offi ce, or location of your choosing. It may cost less than using a retail pharmacy and can help ensure you don’t miss a dose. Simply ask your prescriber to send your prescription to OptumRx’s mail-order pharmacy. Check out this flyer for more home delivery details.
I am going to be out of town for an extended period. How do I get an extra supply of drugs to cover me for that time?
If you are going to be out of town for an extended period and need extra medication, contact Member Services either through the MyRxBenefits member portal or by calling the number on the back of your member ID card to request a vacation override. You must provide the Member Services representative with both the date you are leaving and the date you are returning. RxBenefits will override the quantity limits, and you can pick up your medication at your local pharmacy.
When can I make changes to my benefit elections?
There are only certain times when you can enroll in benefits or make changes – when you’re first hired, during open enrollment, or after a qualifying life event.
So what exactly is a qualifying life event? Certain changes in your personal life qualify as an official change in status according to the IRS, which means that you can modify your benefit selections between open enrollment periods. Examples include changes in family status such as getting married, having a baby, or a change in child custody. In addition, a common qualifying life event is a change in employment status, such as a termination of employment or a change in employment status. Typically, you have 30 days from the date of the event to make changes to your benefits.