Prescription Plan | studentmentalhealth

Pharmacy benefits are managed by Optum Rx on behalf of the UC Student Health Insurance Plan (UC SHIP). There is no annual pharmacy benefit limit. Enrollees may purchase prescribed medications from any pharmacy, but will receive the greatest benefit from an in-network pharmacy.

Prescription and Pharmacy

Billing	Optum Rx PO Box 968022 Schaumburg, IL 60196-8022 1-844-265-1879
Member ID	Call: 1-866-940-8306
Rx Group # BIN Number	UCSHIP 610011
Network	Optum Rx Includes CVS, Safeway, Parnassus Heights (PH) Pharmacy and Walgreens. Call: 1-844-265-1879 https://www.optumrx.com/content/rxmember/default/en_us/angular-free/optumrx/landing.html

Benefit Summary

	IN-NETWORK	OUT-OF-NETWORK
Generic	$5 co-pay	$5, then 60% of billed charges
Brand	$25 co-pay	$25, then 60% of billed charges
Non-formulary Brand	$40 co-pay	$40, then 60% of billed charges
Mail Order (90 day supply)	$15 generic $75 brand $120 non-formulary brand	Not determined at this time.
Prescription Benefit Year Maximum	unlimited	unlimited

Prescription Reimbursement

Students can get partial reimbursement for medication obtained outside of network pharmacies. Students must mail a Prescription Claim Form to the claims administrator within 90 days of the date of purchase. If it is not reasonably possible to submit within that time frame, an extension of up to 12 months will be allowed. Prescription claim forms and customer service are available by calling 1 (844) 265-1879.

Mail Order

To receive your prescriptions via Mail Order with free standard shipping, please complete the OptumRx Home Delivery Form and mail or fax with your maintenance prescription written for a 90-day supply. You also have the option to log onto the Optum Rx website to complete the form online. Once complete you can mail in the paper version of your prescription(s) or fill out a request for Optum Rx to fax your provider.

Information on the member's other medications (prescription and over the counter), allergies, health conditions, and method of payment are required prior to filling a script.

OptumRx Home Delivery
PO Box 2975
Mission, KS 66201
Tel: 1-888-637-5121
Fax: 1-888-637-5191

Out-of-California Network

Formulary