Embed Size (px)
Citation preview
OptumRx administers your pharmacy benefit plan on behalf of your plan sponsor, and we’re here to help you. In addition to answering questions about your plan, we may also be able to help you save money on your prescription medications. We’re committed to you, and your well-being is important to us, so we offer two convenient ways for you to get information that can help you and your doctor make informed decisions about medication therapies.
Dedicated Customer Service
When you call OptumRx at 1-877-559-2955, you get real-time answers and information from our friendly and knowledgeable Customer Service Advocates. We encourage our staff to earn nationally recognized professional certification as certified pharmacy technicians (CPhT) to ensure you receive the best, most comprehensive service from our dedicated team. Customer Service Advocates are available to help you 24 hours a day, 7 days a week.
Easy-to-Use Website
Our website, www.optumrx.com, is easy to use and offers a fast, safe and secure way to refill prescriptions, manage your account, get medication pricing, find medication information and more. Registration is free and there are no extra fees to order online. Website content and services include:
• Locate a pharmacy: a handy tool to quickly find participating pharmacies near you
• My account dashboard: lets you manage your online account and get pharmacybenefit plan information
• Consumer health education: find up-to-date wellness information and learn moreabout your personal health
We welcome questions, comments and suggestions to help us provide you with a truly exceptional customer service experience!
Customer Service
Member Reimbursement Pharmacy FormPlease read the back for instructions. Complete all information. An incomplete form may either delay your reimbursement or may be returned for additional information.
Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement. Submit this form with the original prescription label receipt(s). Cash register and credit card receipts alone are not acceptable as proof of purchase. Reimbursement is not guaranteed. Claims will be reviewed, subject to limitations, exclusions and other provisions of the Plan Benefit.
Member/Subscriber Information (See your ID card.)
RxGrp
Member ID
________________________________________________________________________
Member Name (Last, First)
________________________________________________________________________Street Address
____________________________________________ City State ZIP
Patient Information________________________________________________________________________Patient Name (Last, First)
Patient Date of Birth (Month/Day/Year)
Gender Relationship to Member/Subscriber Female 1 Self 5 Disabled Dependent Male 2 Spouse 6 Dependent Partner
3 Eligible Child 7 Nonspouse Partner 4 Dependent Student 8 Other
Pharmacy and Prescribing Physician Information________________________________________________________________________
Name of Pharmacy
________________________________________________________________________Street Address
____________________________________________ City State ZIP
Telephone (Include Area Code)
X Signature of Pharmacist or Representative NCPDP#/NPI# (Pharmacy Account Number)(11 Digit Number)(If required by your pharmacy plan)
Claim Receipts (Please read Section A on back for details.)Check the appropriate box if your receipts are for a:
Compound prescriptionPlease have your pharmacist complete Section A below. Make sure your pharmacist lists ALL the VALID 11 digit NDC numbers and ingredients and quantities on the claim form.
Medication purchased outside of the United States Please indicate: Country ___________________________ Currency used ______________________
Allergy medication (if covered by your pharmacy plan)
Coordination of Benefits
(Another Health Plan has paid a portion) Is this a coordination of benefits claim?
Yes No
If yes, please read Section B on back for details, and mark the appropriate box for your primary coverage method.
1 You are submitting an Explanationof Benefits (EOB) from another Health Plan or from Medicare
3 You are submitting a copay receipt
Any person who knowingly and with intent
to defraud, injure, or deceive any insurance
company, submits a claim or application containing
any materially false, deceptive, incomplete or
misleading information pertaining to such claim
may be committing a fraudulent insurance act
which is a crime and may subject such person to
criminal or civil penalties, including fines and/or
imprisonment, or denial of benefits.*
Prescribing Physician Name and Phone Number _______________________________________________________________
AcknowledgementI certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself) am eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury. I recognize that reimbursement will be paid directly to me, and that assignment of these benefits to a phPrearmacy or any other party is void.
X Signature of Member/Subscriber
Instructions – Read carefully before completing this form.1. Be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed
below. Your pharmacist can provide the necessary information if your claim is not itemized.
2. The member/subscriber should read the acknowledgment carefully, then sign and date this form.
3. Return the completed form and receipt(s) to: OptumRx ATTN: Claims Department P.O. Box 29077 Hot Springs, AR 71903
Section A – Claim ReceiptsReceipts must contain the following information.
• Date prescription filled • NDC number (National Drug Code) • Prescription number (Rx number)
• Name and address of pharmacy • Name of drug and strength • DAW (Dispense As Written Code)
• Prescribing Physician Name • Quantity and days’ supply or ID number
PHARMACY INFORMATION (For Compound Prescriptions ONLY)
• List the VALID 11 digit NDC number(highest to lowest cost) in the box at right for EACH ingredient used for the compound prescription.
• For each NDC number, indicate the “metric quantity” expressed in the number of tablets, grams, milliliters, creams, ointments, injectables, etc.
• Indicate the TOTAL charge (dollaramount) paid by the patient.
• Receipt(s) must be provided withpatient claim form.
Section B – Coordination of Benefits• You must complete a separate claim form for each pharmacy used and for each patient.
• You must submit claims within one year of date of purchase or as required by your plan.
When submitting an Explanation of Benefits (EOB) from another Health Plan or from Medicare:
If you have not already done so, submit the claim to the Primary Plan or Medicare. Once the EOB is received, complete this form, submit the original prescription receipts, and attach the EOB from the Primary Plan or Medicare, which clearly indicates the cost of the prescription and what was paid by the Primary Plan or Medicare.
When submitting a copay receipt:
If your Primary Plan is one in which a co-payment or coinsurance is paid at the pharmacy, then no EOB is needed. Just complete this form and submit the prescription receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The receipt(s) will serve as the EOB.
X Signature of Pharmacist
RX#Date Filled
Days Supply
VALID 11 digit NDC# Quantity
Total Quantity
Total Charge
102-003 ORX5262_120405
* Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment or a loss is subject to criminal and civil penalties.
* California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Join millions of others who are able to manage the medications they take regularly by using OptumRx® Mail Service Pharmacy. Not only is home delivery safe and reliable, it also offers the following advantages:
Savings
Depending on your benefit plan, you may save money by ordering a three-month supply of medication.
Convenience
You will make fewer trips to the pharmacy and avoid waiting in line. Your medication is shipped directly to your home with standard shipping at no cost to you.
Discover the convenience of OptumRx® Mail Service Pharmacy.
Over
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.
© 2014 Optum, Inc. All rights reserved. OPTPRJ4447 ORX7321_140306
optumrx.com
24/7 phone access to pharmacists
Pharmacists are available 24 hours a day, seven days a week, to answer your questions. They also review your medication for potential harmful interactions with your other medications on file. If there is a potential problem, an OptumRx pharmacist will contact your doctor.
Helpful reminders
Log on to optumrx.com and go to the pharmacy section to set up text* and email reminders that can help you remember to take or refill your medications. You can also set up automatic refills by enrolling in our Hassle-Free FillSM program.
Why wait in line to fill a prescription when you can enjoy the personalized attention and time-saving conveniences of home delivery?
It’s easy to enroll
Just call the member phone number on the back of your plan ID card to talk with a customer service representative right now.
We look forward to serving you.
*OptumRx provides this service at no cost. Standard message and data rates charged by your carrier may apply.
2300 Main Street, Irvine, CA 92614
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.
ORX0799-INV_120714 ©2012 OptumRx, Inc.
www.optumrx.com
Mail Service Saver is a program that helps you better manage the medication you take on an ongoing basis. You can save both time and money by filling your prescriptions for maintenance medication through home delivery with OptumRx. Not only is home delivery safe and reliable, it also offers the following advantages:
Cost savings: You may pay less for your medication with a three-month supply through OptumRx.
Convenience: Get free standard shipping on medications delivered to your mailbox.
24/7 access and reminders: Speak to a pharmacist who can answer your questions any time, any day. Even set up text and email reminders to help you remember to take or refill your medications.*
How Mail Service Saver works
If you are currently taking maintenance medication on a regular basis, your pharmacy benefit plan strongly encourages you to use home delivery.
Your health plan covers only a limited number of maintenance medication refills from a retail pharmacy (call Customer Service at the member phone number on the back of your health plan ID card for the number of fills covered by your specific plan). After the allowed fills, you must move to home delivery through OptumRx or you will pay an increased cost at your retail pharmacy.
Discover the convenience of OptumRx® Mail Service Saver
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.
©2015 Optum, Inc. All rights reserved. ORX7321-MSS_150608 49994-082015
optumrx.com
* OptumRx provides this service at no cost. Standard message and data rates charged by your carrier may apply.
Here is how:
By online registration:Visit optumrx.com, register and follow the simple step-by-step instructions. You can manage your medication online, including filling new prescriptions and transferring other prescriptions to home delivery. You can also set up text message reminders to help manage your medication schedule. Be sure to have your health plan ID card and medication bottles on hand.
By phone:Just call the member phone number on the back of your plan ID card to talk with a customer service representative right now. It’s helpful to have your plan ID card and medication bottle available. The representative can also contact your doctor directly if you need a new prescription.
By mail:Ask your doctor for a new prescription for up to a three-month supply, plus refills for up to one year. Then go to optumrx.com and download the new prescription order form. Mail it to the address provided on the bottom of the form.
By fax / ePrescribe:Ask your doctor to call 1-800-791-7658 for instructions on how to fax your prescription directly to OptumR. Or your doctor can send an electronic prescription to OptumRx.
Whether you have a new prescription or need to transfer an existing prescription, it’s easy to get started with OptumRx home delivery.
Below is a list of all the therapeutic classes of medications included in the mail programs. The most commonly prescribed medications are included under each therapeutic class. It is not inclusive of all maintenance medications that may be included in the mail programs.
The maintenance medication list was determined by taking into consideration chronic, long-term use of a medication, frequency of dose changes and other clinical factors.
If you have questions or are not sure if your medication needs to be filled at the OptumRx® Mail Service Pharmacy, call Customer Service at the member phone number listed on the back of your plan ID card.
Drug Name
Alzheimer’s Disease
ARICEPT
ARICEPT 23 MG*
ARICEPT ODT
DONEPEZIL HCL
EXELON
GALANTAMINE HBR
NAMENDA
NAMENDA XR
RAZADYNE
RAZADYNE ER
RIVASTIGMINE
Asthma/Chronic Obstructive Pulmonary Disease (COPD)
ACCOLATE
ADVAIR DISKUS
ADVAIR HFA
ALVESCO
ARCAPTA NEOHALER
ASMANEX
ATROVENT HFA
BROVANA
BUDESONIDE
COMBIVENT RESPIMAT
DALIRESP
DULERA
DUONEB
DYLIX
FLOVENT DISKUS
FLOVENT HFA
FORADIL
Drug Name
IPRATROPIUM BROMIDE
IPRATROPIUM-ALBUTEROL
LUFYLLIN
MONTELUKAST SODIUM
PERFOROMIST
PULMICORT
PULMICORT FLEXHALER
QVAR
SEREVENT DISKUS
SINGULAIR+
SPIRIVA
SYMBICORT*
THEO-24
THEOCHRON
THEOPHYLLINE ANHYDROUS
TUDORZA PRESSAIR
ZAFIRLUKAST
ZYFLO
ZYFLO CR
Blood Clots/Prevention
ELIQUIS
PRADAXA
XARELTO
Benign Prostatic Hyperplasia (BPH)
ALFUZOSIN HCL
AVODART
CARDURA XL
FINASTERIDE
FLOMAX+
JALYN*
PROSCAR
Drug Name
RAPAFLO
TAMSULOSIN HCL
UROXATRAL
Breast Cancer Prevention
ANASTROZOLE
ARIMIDEX+
AROMASIN
FARESTON
FEMARA+
LETROZOLE
SOLTAMOX*
TAMOXIFEN CITRATE
Chest Pain
IMDUR
ISORDIL
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
MINITRAN
NITRO-DUR
NITROGLYCERIN
NITROGLYCERIN PATCH
RANEXA
Cholesterol/Lipid Lowering
ADVICOR
ALTOPREV*
ANTARA 43, 130 MG
ATORVASTATIN CALCIUM
CHOLESTYRAMINE
CHOLESTYRAMINE LIGHT
COLESTID
COLESTIPOL HCL
Maintenance Medication List
Drug Name
Cholesterol/Lipid Lowering continued…
CRESTOR
FENOFIBRATE
FENOFIBRATE MICRONIZED
FENOFIBRATE 48, 145 MG*
FENOFIBRIC ACID*
FENOGLIDE
FLUVASTATIN SODIUM
GEMFIBROZIL
LESCOL
LIPITOR+
LIPOFEN
LIPTRUZET*
LIVALO
LOPID
LOVASTATIN
LOVAZA
MEVACOR
NIACOR
NIASPAN
PRAVACHOL
PRAVASTATIN SODIUM
PREVALITE
QUESTRAN
QUESTRAN LIGHT
SIMCOR
SIMVASTATIN
TRICOR*
TRIGLIDE
TRILIPIX*
VASCEPA
VYTORIN
WELCHOL
ZETIA
ZOCOR
Constipation
AMITIZA
LINZESS
Contraceptive
ALTAVERA
ALYACEN
AMETHIA
AMETHIA LO
AMETHYST
APRI
ARANELLE
AVIANE
AZURETTE
BALZIVA
BEYAZ*
BREVICON
BRIELLYN
Drug Name
CAMILA
CAMRESE
CAMRESE LO
CAZIANT
CHATEAL
CRYSELLE
CYCLAFEM
CYCLESSA
DASETTA
DAYSEE
DESOGEN
DROSPIRENONE-ETHINYL ESTRADIOL
ELINEST
EMOQUETTE
ENPRESSE
ENSKYCE
ERRIN
ESTARYLLA
ESTROSTEP FE
FALMINA
FEMCON FE
GENERESS FE*
GIANVI
GILDAGIA
GILDESS
GILDESS FE
HEATHER
INTROVALE
JENCYCLA
JOLESSA
JOLIVETTE
JUNEL
JUNEL FE
KARIVA
KELNOR 1-35
KURVELO
LEENA
LESSINA
LEVONEST
LEVONORGESTREL-ETHINYL ESTRADIOL
LEVONORG-ETHINYL ESTRADIOL
LEVORA-28
LO LOESTRIN FE
LOESTRIN
LOESTRIN FE
LORYNA
LOSEASONIQUE
LOW-OGESTREL
LUTERA
MARLISSA
MICROGESTIN
MICROGESTIN FE
Drug Name
MICRONOR
MINASTRIN 24 FE*
MIRCETTE
MODICON
MONO-LINYAH
MONONESSA
MYZILRA
NATAZIA
NECON
NORA-BE
NORETHINDRONE
NORGESTIMATE-ETHINYL ESTADIOL
NORGESTREL-ETHINY ESTRADIOL
NORINYL
NORINYL 1+35
NOR-Q-D
NORTREL
NUVARING
OCELLA
OGESTREL
ORSYTHIA
ORTHO EVRA
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OVCON-35
PHILITH
PORTIA
PREVIFEM
QUASENSE
RECLIPSEN
SAFYRAL*
SEASONIQUE
SPRINTEC
SRONYX
SYEDA
TILIA FE
TRI-ESTARYLLA
TRI-LEGEST FE
TRI-LINYAH
TRINESSA
TRI-NORINYL
TRI-PREVIFEM
TRI-SPRINTEC
TRIVORA-28
VELIVET
VESTURA
VIORELE
WERA
WYMZYA FE
Drug Name
Contraceptive continued…
YASMIN
YAZ
ZARAH
ZENCHENT
ZENCHENT FE
ZEOSA
ZOVIA 1-35E
ZOVIA 1-50E
Diabetes
ACARBOSE
ACTOPLUS MET XR
ACTOS+
AMARYL
APIDRA
APIDRA SOLOSTAR
BYDUREON
BYETTA
CHLORPROPAMIDE
CYCLOSET
DIABETA
DUETACT
FORTAMET
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE-METFORMIN
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
GLUMETZA
GLYBURIDE
GLYBURIDE MICRONIZED
GLYBURIDE-METFORMIN
GLYNASE
GLYSET
HUMALOG
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMULIN 70-30
HUMULIN N
HUMULIN R
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
KAZANO
KOMBIGLYZE XR
LANTUS
Drug Name
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
METFORMIN HCL
METFORMIN HCL ER
NATEGLINIDE
NESINA
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
ONGLYZA
OSENI
PIOGLITAZONE HCL
PIOGLITAZONE-GLIMEPIRIDE
PIOGLITAZONE-METFORMIN
PRANDIMET
PRANDIN
PRECOSE
RIOMET
STARLIX
TOLAZAMIDE
TOLBUTAMIDE
TRADJENTA
VICTOZA
Diabetic Supplies
INSULIN SYRINGE
LANCETS
PEN NEEDLE
Elevated Thyroid Hormone
METHIMAZOLE
PROPYLTHIOURACIL
TAPAZOLE
Glaucoma
ALPHAGAN P
APRACLONIDINE HCL
AZOPT
BETAGAN
BETAXOLOL HCL 0.5%
BETIMOL
BETOPTIC S 0.25 %
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION
CARTEOLOL HCL 1%
COMBIGAN 0.2%-0.5%
COSOPT 2%-0.5%
COSOPT PF 2%-0.5%*
DORZOLAMIDE HCL 2 %
DORZOLAMIDE-TIMOLOL 2%-0.5%
IOPIDINE
ISOPTO CARBACHOL OPHTHALMIC
ISOPTO CARPINE
Drug Name
LATANOPROST
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION
LUMIGAN 0.01%
METIPRANOLOL 0.3%
MIOSTAT 0.01%
PHOSPHOLINE IODIDE
PILOCARPINE HCL
PILOPINE HS
SIMBRINZA*
TIMOLOL MALEATE OPHTHALMIC SOLUTION
TIMOPTIC
TIMOPTIC OCUDOSE
TIMOPTIC-XE
TRAVATAN Z
TRAVOPROST
TRUSOPT 2%
XALATAN
ZIOPTAN
Gout
ALLOPURINOL
COLCRYS
PROBENECID
PROBENECID-COLCHICINE
ULORIC
ZYLOPRIM
Heart Rhythm
AMIODARONE HCL
BETAPACE
BETAPACE AF
CORDARONE
DIGOXIN
DISOPYRAMIDE PHOSPHATE
FLECAINIDE ACETATE
LANOXIN
MEXILETINE HCL
MULTAQ
NORPACE
NORPACE CR
PACERONE
PROPAFENONE HCL
QUINIDINE GLUCONATE
QUINIDINE SULFATE
RYTHMOL
RYTHMOL SR
SOTALOL AF
TAMBOCOR
TIKOSYN
High Blood Pressure
ACCUPRIL
ACCURETIC
ACEBUTOLOL HCL
ACEON
Drug Name
High Blood Pressure continued…
ADALAT CC
ALDACTAZIDE
ALDACTONE
ALTACE
AMILORIDE HCL
AMILORIDE-HYDROCHLOROTHIAZIDE
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE-BENAZAPRIL
AMTURNIDE*
ATACAND
ATACAND HCT
ATENOLOL
ATENOLOL-CHLORTHALIDONE
AVALIDE
AVAPRO
AZOR*
BENAZEPRIL HCL
BENAZEPRIL-HYDROCHLOROTHIAZIDE
BENICAR
BENICAR HCT
BETAXOLOL HCL
BISOPROLOL FUMARATE
BISOPROLOL-HYDROCHLOROTHIAZIDE
BUMETANIDE
CALAN
CALAN SR
CANDESARTAN CILEXETIL
CANDESARTAN-HYDROCHLOROTHIZIDE
CAPTOPRIL
CAPTOPRIL-HYDROCHLOROTHIAZIDE
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA
CARDURA
CARTIA XT
CARVEDILOL
CATAPRES
CATAPRES-TTS
CHLOROTHIAZIDE
CHLORTHALIDONE
CLONIDINE PATCH
CLONIDINE HCL
CLORPRES
COREG
COREG CR*
CORGARD
CORZIDE
COZAAR
DEMADEX
DIAMOX SEQUELS
Drug Name
DIBENZYLINE
DILACOR XR
DILT-CD
DILTIA XT
DILTIAZEM 24HR CD
DILTIAZEM 24HR ER
DILTIAZEM HCL
DILT-XR
DILTZAC ER
DIOVAN
DIOVAN HCT+
DOXAZOSIN MESYLATE
DUTOPROL
DYAZIDE
DYRENIUM
EDARBI
EDARBYCLOR
ENALAPRIL MALEATE
ENALAPRIL-HYDROCHLOROTHIAZIDE
EPLERENONE
EPROSARTAN MESYLATE
EXFORGE*
EXFORGE HCT*
FELODIPINE ER
FOSINOPRIL SODIUM
FOSINOPRIL-HYDROCHLOROTHIAZIDE
FUROSEMIDE
GUANFACINE HCL
HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE
HYZAAR
INDAPAMIDE
INDERAL LA
INNOPRAN XL
INSPRA
IRBESARTAN
IRBESARTAN-HYDROCHLOROTHIAZIDE
ISRADIPINE
KERLONE
LABETALOL HCL
LASIX
LEVATOL
LISINOPRIL
LISINOPRIL-HYDROCHLOROTHIAZIDE
LOPRESSOR
LOPRESSOR HCT
LOSARTAN POTASSIUM
LOSARTAN-HYDROCHLOROTHIAZIDE
LOTENSIN
LOTENSIN HCT
LOTREL
MATZIM LA
Drug Name
MAVIK
MAXZIDE
METHYCLOTHIAZIDE
METHYLDOPA
METHYLDOPA-HYDROCHLOROTHIAZIDE
METOLAZONE
METOPROLOL SUCCINATE
METOPROLOL TARTRATE
METOPROLOL-HYDROCHLOROTIAZIDE
MICARDIS
MICARDIS HCT
MICROZIDE
MINIPRESS
MINOXIDIL
MOEXIPRIL HCL
MOEXIPRIL-HYDROCHLOROTHIAZIDE
NADOLOL
NADOLOL-BENDROFLUMETHIAZIDE
NEPTAZANE
NEXICLON XR*
NICARDIPINE HCL
NIFEDIPINE
NIFEDIPINE ER
NIMODIPINE
NISOLDIPINE
NORVASC
PERINDOPRIL ERBUMINE
PINDOLOL
PRAZOSIN HCL
PRINIVIL
PROCARDIA
PROCARDIA XL
PROPRANOLOL HCL
PROPRANOLOL-HYDROCHLOROTHIAZIDE
QUINAPRIL HCL
QUINAPRIL-HYDROCHLOROTHIAZIDE
RAMIPRIL
RESERPINE
SECTRAL
SOTALOL
SPIRONOLACTONE
SPIRONOLACTONE-HCTZ
SULAR
TARKA
TAZTIA XT
TEKAMLO*
TEKTURNA
TEKTURNA HCT
TENEX
TENORETIC
TENORMIN
TERAZOSIN HCL
Drug Name
High Blood Pressure continued…
TEVETEN
TEVETEN HCT
TIAZAC
TIMOLOL MALEATE
TOPROL XL
TORSEMIDE
TRANDATE
TRANDOLAPRIL
TRANDOLAPRIL-VERAPAMIL
TRIAMTERENE
TRIAMTERENE-HCTZ
TRIBENZOR*
TWYNSTA*
UNIRETIC
UNIVASC
VALSARTAN-HYDROCHLOROTHIAZIDE
VASERETIC
VASOTEC
VERAPAMIL ER
VERAPAMIL ER PM
VERAPAMIL HCL
VERELAN
VERELAN PM
ZAROXOLYN
ZEBETA
ZESTORETIC
ZESTRIL
ZIAC
Hormone Replacement
ACTIVELLA
ALORA
ANGELIQ
CENESTIN
CLIMARA
CLIMARA PRO
COMBIPATCH
COVARYX H.S.
DIVIGEL
EEMT H.S.
ELESTRIN
ENJUVIA
ESTRACE
ESTRACE CREAM
ESTRADIOL
ESTRADIOL TRANSDERMAL PATCH
ESTRADIOL-NORETHINDRONE PATCH
ESTRASORB
ESTRING
ESTROGEL
ESTROGEN METHYLTESTOSTERONE
Drug Name
ESTROPIPATE
EVAMIST
FEMHRT
FEMRING
JINTELI
MEDROXYPROGESTERONE
MENEST
MENOSTAR
MIMVEY
MINIVELLE
NORETHINDRONE ACETATE
OGEN
PREFEST
PREMARIN
PREMPHASE
PREMPRO
PROGESTERONE
PROMETRIUM
PROVERA
VAGIFEM
VIVELLE-DOT
Inflammatory Bowel Disease
APRISO
ASACOL HD*
AZULFIDINE
BALSALAZIDE DISODIUM
CANASA
COLAZAL
DELZICOL*
DIPENTUM
GIAZO*
LIALDA
MESALAMINE
PENTASA*
ROWASA
SF ROWASA
SULFASALAZINE
Myasthenia Gravis
MESTINON
MYTELASE
PROSTIGMIN
PYRIDOSTIGMINE BROMIDE
Osteoporosis
ACTONEL
ALENDRONATE SODIUM
ATELVIA*
BINOSTO*
BONIVA
ETIDRONATE DISODIUM
EVISTA
FOSAMAX
Drug Name
FOSAMAX PLUS D
IBANDRONATE SODIUM
Overactive Bladder
DETROL*
DETROL LA*
DITROPAN XL
ENABLEX*
GELNIQUE*
MYRBETRIQ*
OXYBUTYNIN
OXYBUTYNIN CHLORIDE ER
OXYTROL*
SANCTURA*
TOLTERODINE TARTRATE*
TOLTERODINE TARTRATE ER*
TOVIAZ
TROSPIUM CHLORIDE*
VESICARE*
Pancreatic Enzyme Replacement
CREON
PANCREAZE
PERTZYE*
ULTRESA*
VIOKACE*
ZENPEP
Parkinson’s Disease
AZILECT
BENZTROPINE MESYLATE
BROMOCRIPTINE MESYLATE
CARBIDOPA-LEVODOPA
CARBIDOPA-LEVODOPA-ENTACAPONE
COMTAN
ELDEPRYL
ENTACAPONE
MIRAPEX
MIRAPEX ER*
NEUPRO
PARCOPA
PARLODEL
PRAMIPEXOLE DIHYDROCHLORIDE
REQUIP
REQUIP XL*
ROPINIROLE HCL
ROPINIROLE HCL ER*
SELEGILINE HCL
SINEMET
SINEMET CR
STALEVO
TASMAR
TRIHEXYPHENIDYL HCL
ZELAPAR
Drug Name
Potassium Replacement
KLOR-CON
K-TAB
POTASSIUM CHLORIDE
Seizures
BANZEL
CARBAMAZEPINE
CARBAMAZEPINE ER
CARBATROL
CELONTIN
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
DILANTIN
DIVALPROEX SODIUM
DIVALPROEX SODIUM ER
ETHOSUXIMIDE
FELBAMATE
FELBATOL
GABAPENTIN
GABITRIL
KEPPRA
KEPPRA XR
LAMICTAL
LAMICTAL ODT
LAMICTAL XR
Drug Name
LAMOTRIGINE
LAMOTRIGINE ER
LEVETIRACETAM
LEVETIRACETAM ER
LYRICA
MYSOLINE
NEURONTIN
OXCARBAZEPINE
OXTELLAR XR*
PEGANONE
PHENYTOIN
POTIGA
PRIMIDONE
STAVZOR
TEGRETOL
TEGRETOL XR
TIAGABINE HCL
TOPAMAX
TOPIRAMATE
TROKENDI XR*
TRENTAL
TRILEPTAL
VALPROIC ACID
VIMPAT
ZARONTIN
ZONEGRAN
ZONISAMIDE
Drug Name
Stroke and Heart Attack Prevention
AGGRENOX
BRILINTA
CILOSTAZOL
CLOPIDOGREL
DIPYRIDAMOLE
EFFIENT
PENTOXIFYLLINE
PERSANTINE
PLAVIX+
PLETAL
TICLOPIDINE HCL
Testosterone Replacement
ANDROGEL*
AXIRON*
TESTIM
Thyroid Hormone Replacement
ARMOUR THYROID
CYTOMEL
LEVOTHROID
LEVOTHYROXINE SODIUM
LEVOXYL
LIOTHYRONINE SODIUM
SYNTHROID
THYROLAR
* Brand and/or generic may be excluded from coverage. Lower-cost options are available and covered.+ Brand may be excluded from coverage. Lower-cost options are available and covered.
This is not a complete list of medications, and not all medications listed may be covered under your plan.
Medications subject to change without notice. Not all medications listed may be covered under your benefit plan. Review your benefit plan documents to see what medications are covered under your plan. Where differences are noted between this list and your benefit plan documents, the benefit plan documents will govern. UnitedHealthcare and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated. All branded medications are trademarks or registered trademarks of their respective owners.
This list is subject to change. Please refer to myuhc.com for information on specific drugs included in these programs or call the member phone number listed on the back of your health plan ID card.
M54076-A 4/14 ©2014 OptumRx, Inc.
optumrx.com
NRX001
New PrescriPtioN Mail-iN order ForMMember and physician information — please use black or blue ink. one form per member.
Member ID Number (Additional coverage, if applicable) Secondary Member ID Number
Last Name First Name MI
Delivery Address Apt. #
City State ZIP Phone Number with Area Code
Date of Birth (mm/dd/yyyy) Gender M F
Physician Name Physician Phone Number with Area Code
Health historyMedication Allergies: Aspirin Erythromycin Quinolones Others: None known Cephalosporins NSAIDs Sulfa Amoxil/Ampicillin Codeine Penicillin Tetracyclines
Health Conditions: Asthma Glaucoma High cholesterol Others: None known Cancer Heart condition Osteoporosis Arthritis Diabetes High blood pressure Thyroid Disease
Over-the-counter/herbal medications taken regularly:
Pharmacy processingGeneric substitution. FDA-approved generic equivalents will be dispensed for brand-name drugs whenever possible, unless you or your physician indicate otherwise. Brand-name medications may be subject to a higher cost. If you require brand-name medications, please list those medications here:
Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:
Notes to pharmacy:
Payment and shipping information — do not send cashStandard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications.
For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time.
1
2
3
4
5
Ship overnight. Add $12.50 to order amount (subject to change).
Check enclosed. All checks must be signed and made payable to: OptumRx.
Charge to my credit card on file. Charge to my NEW credit card.
Signature: Date:
New Credit Card Number
Expiration Date (Month/Year) Visa, MasterCard, AMEX and Discover are accepted.
You may log on to www.optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment.
Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
ORX5633_130301
New PrescriPtioN PHYsiciAN FAX order FormUse this form to order a new mail service prescription by fax from the prescribing physician’s office. Member completes section 1, while the physician completes sections 2 and 3. This fax is void unless received directly from physician’s office. To contact OptumRx, physicians may call 1-800-791-7658.
member information — to be completed by memberMember ID Number (Additional coverage, if applicable)
Secondary Member ID Number
Last Name First Name MI
Delivery Address Apt. #
City State ZIP Phone Number with Area Code
Date of Birth (mm/dd/yyyy) Gender M F
Medication Allergies: Aspirin Erythromycin Quinolones Others: None known Cephalosporins NSAIDs Sulfa Amoxil/Ampicillin Codeine Penicillin Tetracyclines
Health Conditions: Asthma Glaucoma High cholesterol Others: None known Cancer Heart condition Osteoporosis Arthritis Diabetes High blood pressure Thyroid Disease
Over-the-counter/herbal medications taken regularly:
Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:
Notes to pharmacy:
Physician and prescription information — physician to complete this sectionPrescribing Physician Name Patient Name DOB
Physician Phone Number with Area CodeEnter prescription details here or attach your office prescription to the form.
Physician Fax Number with Area Code
Physician Street Address
City, State, ZIP
NPI DEA
This document and others if attached contain information from OptumRx that is privileged, confidential and/or may contain protected health information (PHI). We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person(s) or company named above. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately and return the document(s) by mail to OptumRx Privacy Office, 17900 Von Karman, M/S CA016-0101, Irvine, CA 92614.
Refills: 1 2 3 Other: __________________________
Dispense as written: Yes
X_______________________________________ Physician Signature
_____________Date
Physician to fax completed order form to optumrx at 1-800-491-7997.
1
2
3
ORX5510_130903 104-0006 9/1310852
Transfer Prescription to Mail Service
Instructions• PleasecompletethefieldsbelowandhaveyourphysiciancompletethePhysicianSection.• Oncecompleted,yourphysiciancaneither:Faxthisformto1-800-491-7997, ORcallyournew90-dayprescriptioninto
1-800-791-7658, ORyoucanchoosetoreturnthisformbymailtotheaddressbelow.PLEASE NOTE: THIS FORM IS VOID UNLESS SIGNED BY YOUR PHYSICIAN.
• Standarddeliveryisincludedatnocharge.MostordersareshippedviaUSPSandshouldarriveinabout7daysfromthedateyourcompletedorderisreceived.Ifclarificationofyourorderisrequired,deliverytimemaybelonger.
LastName FirstName MI MemberIDNumber
DeliveryAddress Apt.#
City State ZIP PhoneNumberwithAreaCode
DateofBirth(mm/dd/yyyy)
Notes to Pharmacy:
Keep on file. Do not ship. Ifyouareincludinganyprescriptionsthatyouwanttokeeponfileforshipmentatalaterdate,pleaselistthemhere:
Method of Payment: Pleasechargemycreditcardonfile.
CheckEnclosed(makepayableto:OptumRx). HOLDforLATER(CheckonlyifyoudoNOTwantthismedicationfillednow).
Physician Section• YourpatientwouldliketotransferthebelowRETAILprescriptiontotheir90-dayMailServicePharmacy.• Pleasecall1-800-791-7658toorderbyphoneorcompletetherequiredfieldsbelow.Thensign,dateand
eitherFAXtoOptumRxat1-800-491-7997orreturnthesignedformtoyourpatienttosubmitbymail.
PatientName DateofBirth(mm/dd/yyyy)
RetailMedicationQuantityofLastFill
LastFillDate RetailPharmacy Rx#
Required New Qty:
Required Directions:
Required Refills: 1 Yr 0 1 2 3 Other:
PhysicianName OfficePhoneNumberwithAreaCode
StreetAddress FaxNumberwithAreaCode
City,State,ZIP NPI DEA
Physician Signature Date
Thisdocument,includinganyattachments,containspersonalandsensitiveinformationrelatedtoaperson’shealthcare.TheinformationcontainedinthisdocumentisintendedonlyforthesoleuseofOptumRx.Ifyouarenottheintendedrecipientortheemployeeoragentresponsibletodeliverittotheintendedrecipient,youareherebynotifiedthatanydisclosure,copying,distributionoruseofthecontentsofthisinformationisstrictlyprohibitedandwillbevigorouslyprosecuted.Ifyouhavereceivedthisdocumentinerror,pleaseimmediatelynotifythesender,orOptumRxbyphoneorfaxatthenumberslistedbelow.
1
2
ORX7710T-120601
OptumRx,P.O.Box509075,SanDiego,CA92150CustomerService:1-800-562-6223 (TTY711)Fax:1-800-491-7997•www.optumrx.com
optumrx.com is a fast, easy and secure way to get the information you need to make the most of your pharmacy benefit.
Website features and tools
Log into optumrx.com and you will be able to:
• Refill and renew home delivery prescriptions through OptumRx®
• Search for drug prices and view lower-cost alternatives
• Transfer retail prescriptions to home delivery
• Track your OptumRx Home Delivery orders
• View your claims history
• Enroll in text message reminders
• Manage medications for household members1
• View your real time benefits
You can save time, money and improve your health
• Save time — By ordering medications you take regularly online, you make fewer trips to the pharmacy and avoid waiting in line to pick up your medication.
• Save money — Depending on your pharmacy plan, you can order up to a 3-month supply of your medication. Orders are sent using free standing shipping.
Managing your medications online
My medication reminders
Set up text message reminders to help you remember when to take your medication. Text message reminders have been shown to improve medication adherence in persons taking long-term or maintenance medications.2
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.
All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.
© 2017 Optum, Inc. All rights reserved. 64538_042017
optumrx.com
While on the go
Access your pharmacy benefits and manage your prescriptions from your smartphone or tablet with the OptumRx app.3
• Refill or renew home delivery prescriptions
• Transfer a retail prescription to home delivery
• Locate a pharmacy
• Find drug prices and lower-cost alternatives
• View your claims history
• Access your ID card, if your plan allows
• Set up refill reminders
• Set up reminders for when you need to take your medication
We want you to get the most out of your pharmacy plan. The more you know, the more you can save.
Visit optumrx.com today.
1. Dependents or spouses you have access to.
2. Adherence rates quantified using OptumRx internal data for oral anti-diabetic medications among Medicare Part D Beneficiaries, May 2012.
3. App is available for download on both Apple and Android devices.
Download the OptumRx App now from the Apple® App Store or Google Play™.
The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
Free services are provided to help you communicate with us, such as letters in other languages or large print. You may also ask to speak with an interpreter. To ask for help, please call the toll-free phone number listed on your ID card.
ATENCIÓN: Si habla español (Spanish), La compañía no discrimina por raza, color, nacionalidad, sexo, edad o discapacidad en actividades y programas de salud.
Se brindan servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas o en letra grande. También puede solicitar comunicarse con un intérprete. Para solicitar ayuda, llame al número de teléfono gratuito que figura en su tarjeta de identificación.
請注意：如果您說中文 (Chinese)，公司不会基于种族、肤色、国籍、性别、年龄或残疾而在健康计划和活动中歧视任何人。为帮助您与我们沟通，我们提供一些免费服务，例如用其他语言书写的信件或大字体。您也可以要求与口译员对话。欲寻求帮助，请拨打您的 ID 卡上列出的免费电话号码。
Mobile Website
OptumRx Mobile Website
OptumRx now offers a fresh new way to order, refill and review your medications quickly and easily. Our new mobile website lets you access your online account and manage mail service prescriptions from your smartphone – anytime, from anywhere!
Manage Your Prescriptions from Your Smartphone
Now you can use your smartphone to:• Refill prescriptions through OptumRx™ Mail Service Pharmacy
• View your prescription claims history
• Check the status of your mail service orders
• Find network retail pharmacies by ZIP Code or GPS location
• Create and update automated text message reminders
• Search generic and brand-name medications by formulary status or therapy class
When You Need a Reminder
Taking medications as prescribed is an important part of living a healthier life. Our mobile website makes managing your prescriptions (and remembering to take them) easier than ever. Simply use your smartphone to create and send text message reminders about taking and ordering your medications. Reminders like these can help you get the most value from your medications.
Accessing the Mobile Website is Easy
Quick Response (QR) CodeScan the QR code provided here with your smartphone to be automatically directed to www.optumrx.com.
Your Smartphone BrowserYou can also get direct access to our mobile website by entering m.optumrx.com or www.optumrx.com into your smartphone’s browser.
2300 Main Street, Irvine, CA 92614
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.
PSO3537_120629 ©2012 OptumRx, Inc.
www.optumrx.com
BookmarkingOnce the website loads on your phone, simply bookmark it for fast access 24/7.
Take Advantage of Our Full Website and Mobile Site
We designed both websites to work together. If you change your online account or manage your prescriptions from one site, all of your information is automatically updated to the other site as well.
How to Refill Prescriptions
• On the home page, click MY PRESCRIPTIONS. Click REFILL PRESCRIPTIONS. (If you are not logged in, you will be prompted to first log in.)
• Select the mail service prescriptions you would like to refill by checking the boxes.
• Click ADD TO CART to proceed to the Shopping Cart page.
• Review your selections. You can remove items from your cart, continue shopping or check out. When you are done, click CHECK OUT.
• Review your shipping information and order summary. You may change your shipping address or add a new one.
• Review your order summary. To change your order, click BACK. If your order is complete, click SUBMIT.
How to Set up Text Message Medication Reminders
• On the home page, click MY PRESCRIPTIONS. Click MEDICATION REMINDERS. (If you are not logged in, you will be prompted to first log in.)
• Enter the mobile phone number you want to send text message reminders to.
• Enter your time zone.
• Select your mobile carrier from the drop-down box.
• Choose the type of reminder you want to receive. You can get reminders when it’s time to refill or renew mail service prescriptions; when prescriptions are eligible for transfer to the Mail Service Pharmacy; and when orders have been shipped. You can also set up daily reminders for times to take specific medications.
• When you are done, click SAVE.
Don’t let managing your prescriptions tie you down. Just type m.optumrx.com into your smartphone browser and start holding a wealth of helpful information in the palm of your hand.
Over
Download the OptumRx App nowfrom the Apple® App Store or Google Play™.
The OptumRx app
The OptumRx® App makes the online pharmacy experience as simple as possible. You can easily:
• Refill or renew a home delivery prescription
• Transfer a retail prescription to home delivery
• Find drug prices and lower-cost options
• View your prescription claim history or order status
• Locate a pharmacy
• Access your ID card, if your plan allows
• Set up refill reminders
• Track your order
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.
All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.
© 2017 Optum, Inc. All rights reserved. 64826-042017
optumrx.com
The OptumRx App: the most convenient way to manage your prescriptions.
Simple
You can easily refill a medication or transfer a retail prescription to home delivery.
Current
Prescription Drug Lists change frequently; the OptumRx App updates automatically, giving you quick access to the most current drug coverage information.
Personalized
Access a complete profile of your prescriptions when you view your online Medicine Cabinet. You can see all your recent and past prescriptions.
Save time and money
Compare prescription drug options as well as identify potential cost savings.
The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
Free services are provided to help you communicate with us, such as letters in other languages or large print. You may also ask to speak with an interpreter. To ask for help, please call the toll-free phone number listed on your ID card.
ATENCIÓN: Si habla español (Spanish), La compañía no discrimina por raza, color, nacionalidad, sexo, edad o discapacidad en actividades y programas de salud.
Se brindan servicios gratuitos para ayudarle a comunicarse con nosotros, como cartas en otros idiomas o en letra grande. También puede solicitar comunicarse con un intérprete. Para solicitar ayuda, llame al número de teléfono gratuito que figura en su tarjeta de identificación.
請注意：如果您說中文 (Chinese)，公司不会基于种族、肤色、国籍、性别、年龄或残疾而在健康计划和活动中歧视任何人。
为帮助您与我们沟通，我们提供一些免费服务，例如用其他语言书写的信件或大字体。您也可以要求与口译员对话。欲寻求帮助，请拨打您的 ID 卡上列出的免费电话号码。
All Day, All Night Convenience
Our new Prior Authorization Web Portal takes the hassle out of Prior Authorization (PA) requests and follow-up. Using the online portal, you’ll be able to fill out, submit, and check the status of PA requests whenever it is most convenient for you. This time-saving tool not only simplifies your job, but also helps ensure the appropriate use of certain prescription drugs.
Secure Online Access
Using the online Portal is easy. Your first step is to register for an account and create a User ID and Password at www.optumrx.com. Just click Healthcare Professionals and then Prior Authorizations to get started. Once you have been approved for access — typically within 24-72 hours — you will be able to access the Portal to initiate a new PA or check the status of an existing PA.
To create a new PA, simply fill out the online forms with the necessary information and submit via the Portal. If your patient chooses to fill their prescription with one of our pharmacies, please fax a written prescription to 1-800-853-3844. This prescription is necessary to facilitate dispensing and delivery of requested medication.
You will receive a fax confirmation each time you submit a new PA. Cases that require additional research by our pharmacists will display an on-screen message stating that a decision will be both faxed to you and posted on the web within 72 hours.
Making Your Job Easier
As your online gateway to prescription decisions, the Prior Authorization Web Portal is:
• Simple — prompts and drop-down menus guide you through the process
• Convenient — enter requests 24/7/365
• Fast — a decision will be immediate in many cases
• Informative — check status and details of a PA any time of the day or night
Get Started• You will need an Administrator
Account and User Account to submit PA requests through the Web Portal. Go to www.optumrx.com, click on Prior Authorizations, and follow the prompts to create these accounts.
• Then, when you’re ready:— Log-in to the Prior
Authorization Web Portal— Enter provider and
patient information— Enter drug name, strength
and formulation— Provide details of the request
and clinical guidelines— Submit the PA request— Fax the prescription to
1-800-853-3844, if your patient chooses to fill their prescription with us
• You will receive a decision within 72 hours.
OptumRx | www.optumrx.com
Prior Authorization Web Portal Your Easy Online Link to Prescription Decisions
Split Your Pills, Split Your Bill.
Half Tablet
OptumRx | optumrx.com
Half Tablet
As prescription medication costs continue to increase, you may be searching for ways to lower your costs at the pharmacy. You can save up to 50% on your prescription costs by participating in Half Tablet.
You Get the Same Medication and Strength for Half the Cost
With Half Tablet, you take the same medication at the same strength, yet save money on medications you take on a regular basis — up to hundreds of dollars every year.1
Here’s How it Works:2
1. Your doctor writes a new prescription for twice the strength and half the quantity, noting your intent to split the tablets on your prescription.
2. A new prescription is filled and you automatically pay half your usual cost.
3. Split each tablet and take half – you get your usual dose for half the cost.
Savings example
The following example shows how participating in Half Tablet can reduce your cost by half, taking the same tablet at the same strength.
Prescribed: 20 mg of Crestor per day, 30 tablets, 1-month supply.
In this example, you would save $15.00 per month, or $180 annually. Your actual savings will vary based on your medication costs and plan design.
20 mg30 tablets
1-month supply$30 per refill
Your Current Prescription
40 mg15 tablets
1-month supply
$15 per refill
Split each 40 mg tablet into two 20 mg doses.
Half Tablet Program
See if Your Medication Qualifies for Tablet Splitting:
Condition / Therapeutic Class Medications* Member’s Dosage
Tablet Strength to Split
Hypertension (High Blood Pressure)
benazepril (Lotensin®) 5 mg / 10 mg / 20 mg 10 mg / 20 mg / 40 mg
metoprolol ER (Toprol XL®)
25 mg / 50 mg / 100 mg 50 mg / 100 mg / 200 mg
Hypertension (High Blood Pressure) (Alpha Blocker)
doxazosin (Cardura®) 1 mg / 2 mg /4 mg 2 mg / 4 mg / 8 mg
Hypertension (High Blood Pressure)
ACE Inhibitors
fosinopril (Monopril®) 10 mg / 20 mg 20 mg / 40 mg
lisinopril (Prinivil® / Zestril®)
2.5 mg / 5 mg / 10 mg / 20 mg
5 mg / 10 mg / 20 mg / 40 mg
moexipril (Univasc®) 7.5 mg 15 mg
perindopril (Aceon®) 2 mg / 4 mg 4 mg / 8 mg
quinapril (Accupril®) 5 mg / 10 mg / 20 mg 10 mg / 20 mg / 40 mg
trandolapril (Mavik®) 1 mg / 2 mg 2 mg / 4 mg
Hypertension (High Blood Pressure)
Angiotensin Receptor Blockers (ARBs)
candesartan (Atacand®) 4 mg / 8 mg / 16 mg 8 mg / 16 mg / 32 mg
Benicar® 20 mg 40 mg
Diovan® 40 mg / 80 mg / 160 mg 80 mg / 160 mg / 320 mg
irbesartan (Avapro®) 75 mg / 150 mg 150 mg / 300 mg
losartan (Cozaar®) 25 mg / 50 mg 50 mg / 100 mg
High Cholesterol atorvastatin (Lipitor®) 10 mg / 20 mg / 40 mg 20 mg / 40 mg / 80 mg
Crestor® 5 mg / 10 mg / 20 mg 10 mg / 20 mg / 40 mg
pravastatin (Pravachol®) 10 mg / 20 mg / 40 mg 20 mg / 40 mg / 80 mg
simvastatin (Zocor®) 5 mg / 10 mg / 20 mg / 40 mg
10 mg / 20 mg / 40 mg / 80 mg
Depression/ Mental Health
citalopram (Celexa®) 10 mg / 20 mg 20 mg / 40 mg
escitalopram (Lexapro®) 5 mg / 10 mg 10 mg / 20 mg
paroxetine (Paxil®) 10 mg / 20 mg 20 mg / 40 mg
Pexeva® 10 mg / 20 mg 20 mg / 40 mg
sertraline (Zoloft®) 25 mg / 50 mg 50 mg / 100 mg
Diabetes pioglitazone (Actos®) 15 mg 30 mg
Insomnia zolpidem (Ambien) 5 mg 10 mg
* All medication in all lowercase font are the generic form of the brand medication. Both the brand and generic form qualify for tablet splitting.
optumrx.com
The information in this educational tool does not substitute for the medical advice, diagnosis or treatment of your physician. Always seek the help of your physician or qualified health provider for any questions you may have regarding your medical condition.
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.
©2014 OptumRx, Inc. ORX6807_140507
1 This is a voluntary program. Medications subject to change without notice. Not all medications are appropriate for tablet splitting. The medications in this program have been selected because they meet requirements deemed appropriate for splitting. Consult your doctor before splitting any prescription tablets. Only split tablets with a device designed specifically for that purpose. Follow the instructions provided with your tablet splitter.
2 Savings vary based on member medication cost and plan design.
Half Tablet: Split Your Pills, Split Your Bill.
Start saving today. Call your doctor and ask if tablet splitting is right for you.
Free Meter Program
Diabetes can harm your eyes, kidneys, nerves, heart and blood vessels. The impact can be long-term. Regular blood sugar testing can help you avoid these health risks. And it can prevent life-threatening conditions caused by too high or too low blood sugar.
Take Advantage of This Great Offer
To help you monitor blood sugar levels, your pharmacy benefit plan may have the Free Meter Program. With this program, you may be able to get a blood sugar meter at no charge to you. You and your doctor can choose from nine different meters. Information about each meter is inside. For more details, call OptumRx customer service at the phone number on your benefit ID card. Or call the meter manufacturers. Their numbers are inside.
How to Get Your Free Meter
The first step in every diabetes care plan is talking with your health care team. If you would like a new blood sugar meter, tell your doctor or diabetes educator. They will help you select the no-charge meter that’s right for you. Once you decide, it’s easy to place your order. Just call the manufacturer’s Service Center any time.
Your Free Meter Choices Are Inside
Choose From These Brand-Name Meters
Free Meter Program
Choose From These Brand-Name Meters
OneTouch® Ultra 2• Large backlit screen –
Read results day or night
• Result averages – Get 7-, 14- and 30-day averages to see your trends
• Add meal flags – Lets you link the effects of food to your blood glucose results
• Large memory and download port – More ways to review results
OneTouch® UltraMini• Small enough to fit in a purse or pocket
• 2-way scrolling buttons – For simple navigation
• Comes in 6 attractive colors
• 500-test memory – To view recent results
OneTouch® Verio IQ• The first meter ever with
PatternAlert™ Technology
• Spanish language available
• A 750-test memory, color-coded alerts and intuitive navigation
• A bright color display
GLUCOCARD® 01 Meter• Auto code technology
• Shares strips with the GLUCOCARD 01-Mini, so you always have the right strips
• Clinical data confirms high accuracy
• Fewer open test strip bottles for less waste and greater savings
GLUCOCARD® 01-Mini• Fast, accurate test results
with only a tiny sample size • 20 free interchangeable face plates
GLUCOCARD® Vital Meter• Fast, accurate and easy to use
• Auto coded meter has a 250-test memory to help track of your results
• Small 0.5 µL sample size in the GO-based test strip platform gives accurate results in 7 seconds
To order one of these OneTouch® meters call their Service Center at 1-866-355-9962 Order Code: 594PRX100 www.OneTouch.orderpoints.com
To order one of these GLUCOCARD® meters call their Service Center at 1-855-646-3232 No order code required www.glucocardusa.com/optumrx
Choose From These Brand-Name Meters
ACCU-CHek® Aviva Plus• Quick, 5-second results
• Small 0.6 microliter sample size
• 4 customizable test reminders
• Contoured, ergonomic design with easy-to-hold rubber grips
• Made in the U.S.A.1
ACCU-CHek® Nano SmartView• Advanced accuracy with
ACCU-CHEK® SmartView test strips – 23% tighter specification2
• No coding – Fewer steps in testing
• Small, sleek design fits in the palm of your hand
• Brilliant backlit display makes reading numbers easy
1 Using U.S. and imported materials 2 Specifications based on current ISO 15197: 2003
To order one of these ACCU-CHek® meters call their Service Center at 1-877-411-9833 Order Code: RXAC10 http://meters.accu-chek.com
Don’t delay. Talk with your doctor about choosing the best brand-name meter for you. Then order your meter by calling the manufacturer’s Service Center.
