Prescription Drug Coverage
If you enroll in the HOP Medical Plan or the Value Medical Plan (Medicare Supplement plans), you can enroll in the Enhanced Medicare Rx Option, the Basic Medicare Rx Option, or the Value Medicare Rx Option.
Note: You can enroll in these options on a stand-alone basis if you don’t want medical coverage. However, you will not be eligible for Premium Assistance.
If you select a Medicare Advantage plan, your prescription drug coverage is provided with your medical coverage. You cannot select a separate prescription drug coverage option.
Enhanced Medicare Rx Option
- No deductible
- Pays the least of the three options for certain medications
- Includes coverage of certain medications not covered at all under the other two options or Medicare prescription drug programs offered by commercial carriers (see the Bonus Drug List in the back of the formulary)
- Higher premiums than those for the Basic and Value Medicare Rx Options because the Plan provides greater coverage
- Enhanced Medicare Rx Option benefit overview (PDF 40KB)
Basic Medicare Rx Option
- Annual $100 prescription drug deductible (does not apply to generic drugs)
- Lower level of coverage than the Enhanced Medicare Rx Option for certain medications
- Basic Medicare Rx Option benefit overview (PDF 40KB)
Value Medicare Rx Option
- Lowest monthly premium of all three options
- Must satisfy Medicare’s $545 annual deductible (in 2024) before Plan pays any portion of your prescription drug expenses
- Financial protection in the event of unexpected high-cost prescription drug expenses
- After you meet the annual deductible, you pay 25% of the cost of any medication in Initial Coverage.
- Value Medicare Rx Option benefit overview (PDF 39KB)
Download the Medicare Rx Options Comparison Chart (PDF 52 KB) for a side-by-side comparison of all three Medicare Rx Options.
Also review the formulary (list of covered drugs). The Enhanced and Basic Medicare Rx Options have the same formulary. The Value Medicare Rx Option uses a different formulary. There are certain medications that are covered only under the Enhanced Medicare Rx Option (see the Bonus Drug List in the back of the formulary).
Find a drug or pharmacy
Use the tools below to search for drugs by name, tier, or therapeutic class. Note: If you’re enrolled in a Medicare Advantage plan, the drug formulary for that Plan will be different. Check with your Plan for the most updated formulary.
Enhanced and Basic Medicare Rx Options
- Online lookup tools:
- Enhanced and Basic Rx Options: Part D Formulary Lookup Tool
- Enhanced Rx Option: Drug Pricing Tool and Pharmacy Locator Tool
- Basic Rx Option: Drug Pricing Tool and Pharmacy Locator Tool
- Comprehensive Formulary (Effective December 2024) (PDF 2MB)
- Abridged Formulary (PDF 562KB)
- Prior Authorization and Step Therapy criteria documents (Effective December 2024)
Value Medicare Rx Option
- Online lookup tools:
- Gold5 Comprehensive Formulary (Effective December 2024) (PDF 1.6MB)
- Gold5 Abridged Formulary (PDF 320KB)
- Prior Authorization and Step Therapy criteria documents (Effective December 2024)
Exceptions and Appeals
We encourage you to let us know right away if you have questions, concerns, or problems related to the Enhanced, Basic, or Value Medicare Rx Options. Please call our Customer Service numbers as follows:
- For questions regarding the Enhanced, Basic, or Value Rx Options, including the formulary, prior authorizations, mail service orders, Explanation of Benefits (EOB), or the cost of individual drugs, please call OptumRx at 1-888-239-1301.
- For questions regarding eligibility, monthly premium payments, identification cards, or changes in address, please call the HOP Administration Unit at 1-800-773-7725.
A summary of Appeals and Grievances regarding the Medicare prescription drug plans follows. For more details, see the applicable Annual Notice of Changes and the Evidence of Coverage posted to the Documents and Forms page.
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a participant of a Medicare Rx plan. Making a complaint will not affect your participation in this Plan in any way. A complaint will be handled as either a coverage determination, an appeal, or a grievance, depending on the subject of the complaint. The following sections describe each type of complaint.
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are determining both whether to provide or pay for a Part D drug and your share of the cost. Coverage determinations include requests for an exception. You have the right to ask us for an exception if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower copayment. If you request an exception, your doctor must provide a statement to support your request, and your request must meet this Plan’s criteria for an exception.
You or your provider must contact OptumRx Customer Service if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. To contact OptumRx, you may:
- Call OptumRx customer service at 1-888-239-1301, or
- Call the OptumRx prior authorization team at 1-800-711-4555, or
- Have your provider fax OptumRx at 1-844-403-1028.
You can ask us for a coverage determination yourself or name someone else as your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Another person may already be authorized under state law to act for you. To name an appointed representative, you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to:
OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028
You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.
If you need help managing your care, appoint an authorized representative.
An appeal deals with the review of an unfavorable coverage determination. You file an appeal if you want us to reconsider a decision about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
How to file an appeal
If you have an appeal, we encourage you to first call OptumRx Customer Service at 1-888-239-1301. We will try to resolve your concern over the phone. If you request a written response to your phone appeal, we will respond in writing to you. If we cannot resolve your appeal over the phone, we will follow a formal review procedure. Within this process, your appeal will be handled by the Part D Appeal & Grievance Department in accordance with CMS guidelines. You may submit your appeal to the Part D Appeal & Grievance Department by mail or fax to:
OptumRx Prior Authorization Department
c/o Appeals Coordinator
P.O. Box 25184
Santa Ana, CA 92799
Fax: 1-877-239-4565
You will be notified of the appeal ruling within 30 calendar days of the date the grievance was filed. Exceptions to the 30-day ruling time frame may be made in accordance with CMS guidelines to accommodate extensions and expedited issues. If your appeal involves a refusal to grant an expedited coverage determination or expedited appeal and you have not yet purchased or received the drug in dispute, the appeal ruling will be communicated to you within 24 hours of receipt. We must notify you of our decision about your appeal as quickly as your case requires, based on your health status, but no later than 30 calendar days after receiving your appeal. We may extend the time frame by up to 14 calendar days if you request the extension or if we justify a need for additional information and the delay is in your best interest.
A grievance is any complaint other than one that involves a coverage determination. A grievance is different from a request for a coverage determination, because it usually will not involve coverage or payment for Part D prescription drug benefits. (Concerns about our failure to cover or pay for a certain drug should be addressed through the coverage determination process discussed above.)
You file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.
How to file a grievance
If you have a grievance, we encourage you to first call OptumRx Customer Service at 1-888-239-1301. We will try to resolve your concern over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we will follow a formal review procedure called “Processing of Expedited and Standard Grievances for Medicare Part D.” Within this process, your grievance will be handled by the Part D Appeal & Grievance Department in accordance with CMS guidelines. You may submit your grievance to the Part D Appeal & Grievance Department by mail, phone, or fax to:
OptumRx
Attn: Part D Grievances
P.O. Box 3410
Lisle, IL 60532
Fax: 1-866-235-3171
You will be notified of the grievance ruling within 30 calendar days of the date the grievance was filed. Exceptions to the 30-day ruling time frame may be made in accordance with CMS guidelines to accommodate extensions and expedited issues. If your grievance involves a refusal to grant an expedited coverage determination or expedited appeal and you have not yet purchased or received the drug in dispute, the grievance ruling will be communicated to you within 24 hours of receipt. We must notify you of our decision about your grievance as quickly as your case requires, based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the time frame by up to 14 calendar days if you request the extension or if we justify a need for additional information and the delay is in your best interest
Reporting Fraud
The Medicare prescription drug benefit was implemented by the Centers for Medicare & Medicaid Services (CMS) to allow all Medicare beneficiaries access to prescription drug coverage beginning on January 1, 2006.
Medicare is interested in receiving reports of potential fraud, waste, or abuse from Medicare beneficiaries.
- An individual or organization pretends to represent Medicare and/or Social Security and asks you for your Medicare or Social Security number, bank account number, credit card number, money, etc.
- Someone asked you to sell your Medicare prescription drug card.
- Someone asked you to get drugs for them using your Medicare prescription drug card.
- You feel a Medicare prescription drug plan has discriminated against you, including not letting you sign up for their plan because of your age, health, race, religion, or income.
- You were encouraged to disenroll from your plan.
- You were offered cash to sign up for a Medicare prescription drug plan.
- You were offered a gift worth more than $15 to sign up for a Medicare prescription drug plan.
- Your pharmacy did not give you all of your drugs and had no plans to provide the drugs to you for your prescription at a later time.
- You were billed for drugs that you didn’t receive.
- You believe that you have been charged more than once for your premium costs.
- Your Medicare prescription drug plan did not pay for your covered drugs.
- You received a different drug than your doctor ordered, and your doctor did not allow a substitution.
Please contact Medicare at 1-800-MEDICARE (1-800-633-4227) to report complaints about one of these types of fraud, waste, or abuse issues or a related complaint.
If you have a general question or concern related to your Medicare drug benefit and it is not a potential fraud, waste, or abuse issue, please contact the HOP Administration Unit at 1-800-773-7725 or call 1-800-Medicare. You may also contact the PSERS fraud, waste, or abuse hotline at 1-800-778-2703 or 717-772-3883.
Last Modified: November 30, 2024
