Coverage under the Market-Priced Drug (MPD) Program—applies to Indemnity PPO Medical Plan and UnitedHealthcare SignatureValueTM Flex HMO Participants
The Market-Priced Drug (MPD) program applies to Indemnity PPO and UHC HMO Medical Plan Participants. The MPD program helps you and your doctor identify lower cost prescription drugs for treating common chronic health conditions. The MPD program does not apply for those enrolled in the Kaiser Permanente HMO Plan.
Under the MPD program, lower cost drugs are called “Preferred” Drugs or “Preferred MPD” Drugs. When you use a Preferred Drug included in the MPD program, you will pay the lowest copayment. However, if you use a drug that is not on the Preferred Drug list (known as a “Non-Preferred” Drug) to treat the same condition, your out-of-pocket cost will be much higher.
The MPD program covers medications for several common, chronic medical conditions, including:
- High Cholesterol
- High Blood Pressure
- Heart Rhythm/Chest Pain
- Muscle Relaxants
- Acid Reflux
- Inflammatory Conditions
- Pain Management
- Hormone Replacement
- Parkinson’s Disease
- Additional conditions (e.g., osteoporosis, hair loss, erectile dysfunction)
The Fund’s pharmacy benefits management vendor, OptumRx, periodically reviews each Participant’s prescription drug history. If you are using a Non-Preferred Drug when a Preferred MPD Drug alternative is available, you will receive a personalized letter that outlines the medications affected by this program, the suggested MPD alternative, and your estimated savings from switching. The letter will also explain the exception process your doctor can follow if she or he believes that a change in your medication is clinically inappropriate.
The list of MPD-covered conditions and drugs changes from time-to-time, so be sure to contact OptumRx to verify a drug’s status. For a list of your current prescriptions, preferred drugs and pricing, visit www.OptumRx.com.
You will pay less for MPD Preferred Drugs and more for Non-Preferred Drugs. Here’s how it works.
- When you use Preferred Drugs: You pay your plan’s regular copayment or the drug’s market price if it’s less than the copayment.
- If you choose Non-Preferred Drugs: You pay your plan’s regular copayment plus the actual difference in price between the Non-Preferred Drug and the Preferred Drug. This is called the “Drug Cost Difference.” See an example below. Note: The MPD program applies to prescriptions filled at a retail pharmacy and through mail order.
If you are taking prescription drugs, be sure to tell your doctor about the MPD program right away. Under the MPD program, your physician may request a medical exception from the program if there is a recognized medical reason you should not take a Preferred Drug, such as:
- You tried the Preferred Drug and it doesn’t work as well as the Non-Preferred Drug.
- The Preferred Drug won’t work with other medications you are taking.
To request a medical exception, your doctor will need to complete this Market-Priced Drug Exception Request form. They may also call OptumRx at 888-715-7573 (TYY 711) to request one. Once completed, your doctor should submit the form to OptumRx via fax: 800-527-0531. OptumRx will review the request and notify you and your doctor of its decision.
If an exception is approved, the Preferred Drug copayment will apply
Following is an example of how costs compare for a Preferred Drug versus a Non-Preferred Drug.
*This is only an example. Drug prices may vary, and your actual copayment may differ
|Preferred Drug||Non Preferred Drug||Non-Preferred Drug (When exception is approved by OptumRX)|
|azelastine hcl (nasal)
You pay regular copayment: $10.00
|Astepro SPR 0.15%
You pay regular copayment: $10.00
- By phone—888-715-7573. OptumRx call center representatives are available Monday through Friday, 7 a.m. – 7 p.m. PT, to answer questions about the MPD program.
- Online. Visit OptumRx’s online Medicine Cabinet: www.OptumRx.com. The Medicine Cabinet will help you make informed choices about Preferred alternatives to Non-Preferred Drugs. Have your medical plan ID card handy—you’ll need your member ID number from the card to use the site. Through the site you can:
- Review drug costs and find lower-cost alternatives.
- Calculate annual costs and savings.
- Print information about MPD alternatives to discuss with your doctor.