Prescription Drugs

Optima Medicare HMO plans offer the convenience of medical and Part D prescription drug coverage all in one plan. Part D coverage may help lower your prescription drug expenses and protect against higher costs in the future.

Formularies

A formulary is a list of covered drugs. Optima Medicare HMO has a single formulary for 2020, although coverage may vary by your chosen plan.

The Optima Medicare HMO formulary is available for use by Optima Medicare members.


Note: Quantity Limits, Step Therapy Criteria and Prior Authorization forms can be found under Prescription Drugs in the member portal.

Pharmacy

Access over 1,500 quality pharmacies

You can search our pharmacy network using our convenient online pharmacy locator tool. Please refer to the printable directories to locate a specific pharmacy type.

Search Online

Our pharmacy directory includes information on:

  • Retail chain pharmacies.
  • Our mail order pharmacy vendor, OptumRx.
  • Other pharmacies (independent retail, long-term care, and home infusion pharmacies).


Note: The inclusion of a pharmacy in the directory does not guarantee that the pharmacy is open or is at the same location as listed in the directory. Listing does not guarantee participation in the network. All network pharmacies may not be listed in the directory.

Frequently Asked Questions

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Below are some frequently asked questions and other information about our prescription drug formulary listings. Information on requesting exceptions and determinations can be found under Prescription Drugs in our member portal.

  • What if my prescriptions are not listed?

    If you have any questions, please call OptumRx (pharmacy benefit manager for Optima Medicare HMO) at 1-866-603-7514. TTY users call 711. You can call 24 hours a day/7 days a week.

  • Transition of Care Process

    When you join our Plan as a new member, you may be taking drugs that are not on our formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to determine what is best for your care. During the first 90 days of your new membership, Optima Medicare may provide a temporary supply of a drug which is not on our formulary or which has restrictions. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary refill supply for the drug during the first 90 days of the new plan year.

    We will provide a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy for a Part D drug that is not on our formulary or that is subject to restrictions, such as prior authorization or step therapy. You can only receive one temporary 30-day supply as part of our transition process. After you receive the temporary 30-day supply, we will provide you with a written notice explaining the steps you can take to request an exception and how to work with your doctors if you should switch to a drug we cover.

    For Members in a Long-Term Care Facility (like a nursing home)

    If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary transition supply (unless you have a prescription written for fewer days). The first supply will be for a maximum of 98-days, or less if your prescription is written for fewer days. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 34-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. This is in addition to the initial transition supply provided.

    If a current member transitions to a different level of care, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days) and cover more than one refill during the first 90 days if the member transitions into a long-term care facility. If the transition is out of a long-term care facility, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when the member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

  • Medication Therapy Management Program

    Better therapeutic outcomes for members with multiple conditions

    Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. This program is administered by OptumRx®, our pharmacy benefits manager. Optima Medicare members can participate in this program at no cost. There is no change to insurance benefits, co-pays/coinsurance, prescription coverage, or available doctors or pharmacies while in this program.

    To qualify for MTMP, a member must meet all of the following criteria:

    • Members must have filled four or more chronic Part D medications; and
    • Members must have at least two of the following chronic conditions — Asthma, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Depression, Diabetes, Dyslipidemia, HIV/AIDs, Hypertension, Osteoporosis, and Rheumatoid Arthritis; and
    • Members must be likely to incur annual costs of $4,044 in 2019 ($4,255 in 2020) or more for all covered chronic Part D medications.

    The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

    • Ensuring they take their medications correctly
    • Improving medication adherence
    • Detecting potentially harmful medication uses or combinations of medications
    • Educating members and health care providers

    Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians, and PhDs develop, manage and evaluate the programs for effectiveness.

    One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.

    Comprehensive Medication Review (CMR)

    The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.

    The CMR includes three components:

    1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or "behind the scenes" by a qualified provider and/or using computerized, clinical algorithms.
    2. An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
    3. An individualized, written summary of the consultation for the member, including but not limited to, a personal medication list (PML), reconciled medication list, action plan, and recommendations for monitoring, education, or self-management.

    View or download a copy of the Personal Medication List.

    If you have any questions about the MTM program, please call the OptumRx MTM Department at 1-866-352-5305, Monday - Friday, 8 am to 8 pm CST. TTY users call 711.


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