senior woman picking up her medication

Pharmacy FAQs

Below are commonly asked questions about our Pharmacy Services. Please click on the question to see the answer.

Formulary and Benefit Coverage FAQs

What is a Formulary?

The formulary is a list of covered and preferred brand and generic drug products for Hometown Health members. The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists (Pharmacy and Therapeutics (P&T) Committee) meets quarterly to decide which drugs should be on the drug list. The P&T Committee reviews new and existing drugs and chooses drugs that work best and are proven to be safe. Consequently, the formulary is updated regularly and subject to change without notice. The formulary is a good source for you and your provider to determine the best drug for your condition, at the lowest out-of-pocket expense to you. Ultimately, specific drug product selection for an individual member is dependent on your prescriber.

How do I use my formulary?

You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed here, please visit your plan’s website or call the number on your member ID card.

What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor.

When does the formulary change?
  • Medications may move to a lower tier at any time.
  • Medications may move to a higher tier when a generic equal becomes available.
  • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. If a medication changes tiers, you may have to pay a different amount for that medication.
Where can I find my formulary?
What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. In some situations, brand-name medications could be lower in cost.

What if my doctor writes a brand-name prescription?

If your doctor gives you a prescription for a brand-name medication, ask if a lower-cost option could be right for you.

What if I am taking a specialty medication?

Specialty medications are used to treat complex conditions and are generally higher in cost. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask how you can have your prescriptions delivered right to your home or doctor’s office.

Where can I find information regarding which medications have coverage requirements (step therapy, quantity limits, tiering information, etc.)?
  1. For individual drug information you will need to log into your Optum account (link here: Optum Rx – Affordable, Free Prescription Delivery | Optum Rx) and then under “Member Tools” use the “Drug Pricing and information” tool to individually look up each medication. This will give you pricing information regarding the exact drug name, strength, and amount that you entered at in-network pharmacies close to you. This will also allow you to see the cost for mail order.
  2. To find which medications have coverage requirements you can use this link: (Drug Formularies | Senior Care Plus) and then scroll down to the your plan’s “Online Formulary” or “Printable Formulary”.
    1. The Online Formulary will allow you to search for one individual medication at a time. You will type your medication name into the search tab and then it will return the results for that medication. It will display the results of the tier level coverage of the medication along with any restrictions. To find out what restrictions there are you will need to click on the drug name, and it will bring up that information.
    2. The Printable Formulary is a list of all formulary medications. You can scroll through the list to find your medication. It has a table at the beginning of the document that lists what the individual letters/numbers next to a medication name mean. For further detailed information you would want to use the Online Formulary.
  • The first 3 pages of the Printable Formulary are information regarding the formulary and the symbols used within it.
What is a quantity limit and why do we have them?

A quantity limit is when a drug is only allowed to be filled for a certain amount over a specific period of time. These are in place for safety reasons. If you or your provider feel that your condition needs more than the quantity limit allows, an exception request can be submitted. That form can be found here: Forms | OptumRx

How do I request an exception?

Please click this link to find the form. This form must be completed fully with all questions answered and all necessary information provided (for example: patient-specific clinical information, previously tried therapies, etc) when submitting the form for the exception request.

What can I expect to pay?

Optum Rx – Affordable, Free Prescription Delivery | Optum Rx – log in to your Optum account and use the “Drug Pricing and information” tool under Member Resources to search individual medications for the estimated cost.

How can I save on prescriptions?

Optum Rx – Affordable, Free Prescription Delivery | Optum Rx – log in to your Optum account and use the “Drug Pricing and information” tool under Member Resources to search individual medications for -prices at different in-network pharmacies near you.

What is an excluded medication?

Certain drug products have been excluded from this formulary. If you choose to use an excluded drug product Hometown Health may not reimburse for these drug products and may require you to pay 100% of the cost. Furthermore, if you choose to use a drug that is not on formulary or excluded, the cost, does not accumulate towards meeting your annual deductible or out of-pocket maximums.

Why might a medication be excluded?

Certain classes of medication are not covered under your pharmacy benefit. These medication classes may include but are not limited to: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hematinic, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications.

Will I be charged more if I want a brand name medication over its generic version?

An ancillary charge may apply to brand medications when an equivalent generic is available. If a member or provider, chooses a brand medication over the generic medication, the member may be responsible for their copay/coinsurance plus the cost difference between the brand medication and the generic medication (ancillary charge). Ancillary charges do not accumulate towards meeting your annual deductible or out of-pocket maximums.

How do I know if a medication will apply to my pharmacy benefit?

The formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If an inpatient medication has been prescribed your doctor must contact Hometown Health customer service to obtain benefit coverage information specific to your plan design for your medical benefits.

What if my drug is not listed on the formulary?

To avoid delays in access to your treatment, your provider may check the formulary to prescribe a covered drug that is best for you. The Hometown Health formulary offers a wide coverage of available drugs. However, in instances where the drug is rejected due to “Drug Not Covered”, you may either:

  • Ask your pharmacy to contact your provider to change the prescription to a covered formulary alternative.
  • If your provider believes the non-covered product is “medically necessary” for your condition, your provider may request an “Exception” for coverage. See the next section for information on how to request an exception.
How do I request an exception?

Members or providers can ask Hometown Health to make an exception to our coverage rules. Exceptions are reviewed for medical necessity, your inability to use covered drugs (e.g., side effects, contraindications, allergies), current covered products may not be effective for you, and new drug entrants that have not yet been reviewed and placed on the formulary.

What can I expect to pay?

What you expect to pay depends on the type of drugs your provider ordered for you. Each drug is placed in a tier level; different tiers represent the different levels of payment for covered medications. Tier structures are developed to encourage you to use quality products at the most cost-effective option to you. The lower cost option does not represent a lower quality product. Rather it is the best cost option considering covered products within that treatment category. You can be assured that drugs provided through your pharmacy benefit has been through rigorous processes to be approved by the FDA.

  • Tier 1: This tier represents lowest out-of-pocket expense. This tier includes select generics.
  • Tier 2: This tier represents the next lowest out-of-pocket expense. This tier generally includes preferred brands but may also include select generics.
  • Tier 3: This tier represents a moderate out-of-pocket expense. This tier includes nonpreferred brands and non-preferred generics (typically have similar alternatives at a lower tier level).
  • Tier 4: This tier represents the highest out-of-pocket expense and is reserved for Specialty Medications/Injectable medications. This tier includes brands and nonpreferred high-cost generic medications.
Why are there generics on different tiers?

With the increases in availability of high-cost specialty drugs and slowed developments of new active ingredients in the traditional drugs, some older drugs have been reformulated to create a new brand drug, or some generics have been rebranded by other companies to offer the same active ingredient drugs at a higher cost than previous generics. Although our tier structure still remains with most generics in the lower cost tiers, the high-cost generics with lower cost alternatives may be moved to the higher cost tiers to encourage you to use the more cost effective options.

How can I save on prescriptions?

Here are some other tips to pay less out of pocket for your prescription drugs:

  • Ask your provider to consider prescribing generic drugs instead of brand-name drugs.
  • Ask your provider to consider prescribing drugs that are on our Formulary.
  • Fill your medications at our mail-order home delivery pharmacies.
  • Check drug prices at different in-network pharmacies in the portal through MyChart.

Mail Order FAQs

What is the benefit of using mail order pharmacy?

Members are encouraged to take advantage of the mail order pharmacy benefit for cost-savings, convenience, and safety. For most members, you will pay 2 times the 30-day co-pay for a 90-day supply, enjoying the cost-savings of one month supply. With mail order pharmacy, members can fill their prescriptions by mail, phone, fax or online at any time and can enjoy the convenience of prescriptions being delivered to the address of their choice. And, if members are taking multiple medications on a regular basis, the pharmacy will track your medications and monitor strength, dosage, and any potential interactions to help keep you safe and healthy.

How will my prescriptions be mailed to me?

Your medications are sent via first class mail by the US Postal Service to a physical address. The mail order pharmacy will not deliver to a P.O. Box. Refrigerated medications, such as insulin, are shipped UPS or FedEx overnight at no additional cost to you.

How long does it take to receive my prescriptions after I set up my new account with the mail order pharmacy?

You should receive your first shipment from the mail order pharmacy within two weeks unless the prescription requires an outreach to your provider.

How is packaging set up to handle extreme cold or hot temperature?

Mail order pharmacies send all refrigerated medications in special packaging (Styrofoam and cardboard inserts) with predetermined requirements for the number of ice packs for the box size and they are shipped overnight. Non-refrigerated medications do not ship with any special packaging.

What mail order pharmacies are in-network and how can I sign up?
Accordion Content

Prescription Co-Payment/Co-Insurance FAQs

What is a prescription co-payment and/or co-insurance?

A prescription co-payment and/or co-insurance is the portion of the covered drug that you are required to pay each time you fill a prescription, Hometown Health pays the remainder. Usually, the co-payment is a flat dollar amount, and the co-insurance is a percentage amount of the drug cost. There are usually different co-payments for the generic, brand formulary, and brand non-formulary drugs. Check your Evidence of Coverage (EOC) for your specific co-payment information.

What is a pharmacy benefit deductible?

Some plans may have a pharmacy benefit deductible, which is the set dollar amount which must be paid by you for each calendar year for covered prescriptions before your co-payments, and/or co-insurance apply.

How can I pay a lower co-payment on a prescription?

When a provider prescribes a brand-name medication, you should ask if a generic drug is available to treat your condition. If a generic drug is not available to treat your condition, your co-payments will be lower if your physician selects a formulary over a non-formulary brand name drug.

What does “participating pharmacy” mean?

“Participating pharmacy” means a pharmacy has an agreement with Hometown Health to provide covered services to our members.

Where can I find my participating pharmacies?

There are two places to find this information. You can use this link to Pharmacy Search | Senior Care Plus or you can log into your OptumRx account : Optum Rx – Affordable, Free Prescription Delivery | Optum Rx and use the Pharmacy Locator tool under Member Resources

What happens if I use a non-participating pharmacy?

Our drug benefits do not include coverage for non-participating pharmacies unless the prescription is obtained in conjunction with a covered emergency. If you fill your prescription at a non-participating pharmacy in an emergency, you must pay the pharmacy the entire cost of the prescription and then submit a direct member reimbursement form to Hometown Health. If the claim is approved, your co-payment or co-insurance may be more or less than you have paid to the pharmacy than if you had used a participating pharmacy. Depending on the design of your benefit, you will also be responsible for any deductibles, and applicable co-payment/co-insurance. Check your Evidence of Coverage (EOC) for your specific co-payment/co-insurance information.

Why does my co-payment seem to change each refill?

If a medication cost (usually generic) is less than your monthly co-pay, Hometown Health offers that price to the member. For example, if your generic Tier 1 co-pay for 30 days’ supply is $15.00. The most you will ever pay for generic Tier 1 medication is $15.00 if the network pharmacy submits a cost of $7.50, for the Tier 1 generic you pay the $7.50. Therefore, the cost can fluctuate each month based on the current cost of the medication. This may cause you to see a change in your co-pay each time you refill.

I am going on vacation and will need an extra supply of medications, what should I do?

If your medication is due to be refilled while you are on vacation, you can have it filled at one of Hometown Health’s participating pharmacies nationwide. Depending on your pharmacy benefits, you may also be able to call us and request an early refill authorization at your regular pharmacy which will allow you to pick up your prescription before you leave. To request an early refill authorization, please call the pharmacy services number on the back of your member ID card. If you use our mail order pharmacy, you can also request that your refill be shipped to a different address while traveling.

If your question isn’t listed here, check your Evidence of Coverage or call the Pharmacy Services number listed on the back of your Hometown Health ID card for assistance.