Coverage

 

PRESCRIPTION DRUG BENEFITS

The OU Health Plan utilizes EmpiRx and Silver Scripts  as the Plan’s Prescription Drug Manager (PBM).

What is Covered? – The OU Plan covers drugs that must be prescribed by a Professional Provider, and approved by the FDA for the treatment or for specific diagnosis or condition. The drug must also be Medically Necessary treatment of the condition for which the drug is prescribed, and not Experimental and Investigational as defined in the Plan Document, unless otherwise required pursuant to an external appeal. Insulin and oral agents for controlling blood sugar are provided through the prescription drug program, as are other diabetic supplies.

Generic equivalents of prescribed drugs will be provided unless specifically prohibited by the prescribing physician. If you choose to obtain a brand name drug when a generic equivalent is available, you will be responsible to pay the additional excess charges.

How the Program Works. – If you purchase drugs at a participating (in-network) pharmacy or through the mail order pharmacy, your co-payments depend upon the category of the drug purchased. Generic drugs cost the least, while preferred drugs and non-preferred drugs are more expensive. For a list of preferred drugs (PDL), see the Pharmacy Benefit Manager’s website at EmpiRxhealth.com and SilverScript.com

Using the Mail Order Pharmacy. – If you choose, you may order a 90-day supply of long term or maintenance drugs through the mail order pharmacy or at your local CVS drug store. Three refills of mail order drugs may be obtained under each prescription order. Your co-pays will be less for mail order drugs than for drugs you refill monthly at the drug store. Drugs purchased through the mail order service will be sent directly to your home, postage paid. You can contact EmpiRx Customer Service at 1-877-241-7123.

The table below shows your co-pay for drugs, depending on the type of drug (generic, preferred or non-preferred) and whether you obtain the drug at a retail drug store, through the mail order pharmacy or at your local drug store.

Example below. See Plan Document for additional information.

In-Network Retail Provider Mail Order
Generic drugs $5 co-pay for 30-day supply Mail order is $10 for a 90-day supply.
Preferred brand drugs $35 co-pay for 30-day supply Mail order is $70 for a 90-day supply.
Non-preferred brand drugs $60 co-pay for 30-day supply Mail order is $120 for a 90-day supply.
Specialty drugs Call EmpiRx  at 1-877-241-7123 for details.

 

Drugs that Require Prior Authorization – Certain drugs that may be prescribed by your doctor require that the pharmacist contact the pharmacy benefit manager for verification of coverage. These drugs include those used to treat migraines, obesity, ADD, narcolepsy and arthritis, etc. The pharmacist will let your physician know if there are any authorization or limitation requirements on the prescribed drugs.

Latest News

The OU Health Plan has arranged with EmpiRx to offer the flu vaccine to Plan members for a $0 copay

To receive your FREE Flu Vaccine, COVID-19 vaccination or COVID-19 booster shot simply go to any participating pharmacy and present your OU Health member ID card.


MEDICARE PRIMARY RETIREES:

To receive your Free Flu Vaccine or COVID-19 vaccine or booster shot, simply go to any pharmacy that participates with the CVS Caremark/ Silver Script network of pharmacies and present your Silver Script Prescription ID card.


Note to all members: This year, please consider obtaining the flu shot in October, before the flu season starts, as medical experts have advised co-exposure to both COVID-19 and the flu could result in serious illness such as pneumonia and respiratory distress, hospitalization or even death. This is possible because the flu and COVID-19 are caused by different viruses.

***OU Health announces EmpiRx Health as the new Pharmacy Benefits Manager effective July 1, 2021***

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CORONA VIRUS TESTING

The Orange Ulster School Districts Health Plan will provide 100% coverage for in-network diagnosing and laboratory testing for the potential Corona Virus office visit or Live Health Online (Telemed) visit. Click here to download

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