Medical and Prescription Drug Coverage
Medical and Prescription Drug Coverage
See Medical Care and Prescription Drug Summary Plan Description for more details.
Visit the RIT Service Center for questions about your benefits.
General Information
Regular full-time and part-time employees scheduled to work nine or more months are eligible to participate in the plan 12 months per year; regular full-time and part-time employees scheduled to work less than nine months are eligible to participate in the plan when working at RIT.
Employees may cover their spouse/domestic partner and children up to age 26. RIT pays the majority of the medical premiums for employees. Employee premium costs vary based on plan, coverage level and employee salary level.
If you elect coverage as new hire, coverage begins on the first day of the month on or after your date of employment.
You need to enroll during your initial new hire enrollment period, during a mid-year qualifying event where you lost Medical/Rx coverage or during an annual Open Enrollment period. If you enroll during an Open Enrollment period, your coverage will be effective on January 1 of the upcoming year.
The Medical and Prescription Drug coverage has two Claims Administrators:
| Plan | Vendor | Contact info |
| Medical Coverage | Excellus BlueCross BlueShield | 800-724-1675/V and 585-454-2845/TTY |
| Prescription Drug | OptumRx | (855) 209-1300 |
Each person covered by a POS plan (A, B or D) should have a Primary Care Physician (PCP) listed at Excellus. The specialist copay will apply for any visit to a primary care physician who is not listed as the PCP. You can change your PCP at any time by logging into your online account with Excellus or contacting customer service at 1-877-253-4797.
A PCP is not required for those covered by the Blue PPO.
| In-Network Medical Coverage | POS A | POS B and POS B No Drug | POS D | |||
| RRH(1) | Other In-Network | RRH(1) | Other In-Network | RRH(1) | Other In-Network | |
| Annual Deductible (individual/family) | Not Applicable | $250/$500 | $300/$600 | |||
| Coinsurance (patient pays/plan pays) | Not Applicable | 10%/90% | 10%/90% | |||
| Annual Patient Maximum Out-of-Pocket (individual/family) | $5,450/$10,900 | $6,450/$12,900 | $6,800/$13,600 | |||
| Telemedicine with MD Live | N/A | $10 | N/A | $10 | N/A | $10 |
| RRH On-Campus Practice | $20 | N/A | $20 | N/A | $20 | N/A |
| Primary Care Physician | $30 | $35 | $35 | $40 | $40 | $45 |
| Specialist | $35 | $50 | $40 | $55 | $45 | $60 |
| Physical Therapy | $50 | $55 | $60 | |||
| Urgent Care | $55 | $60 | $65 | |||
| Emergency Room | $115 | $140 | $140 | $190 | $165 | $215 |
| Hospital Inpatient | $150 | $200 | 10% coinsurance after deductible | 10% coinsurance after deductible | ||
| Hospital Outpatient or Ambulatory Surgical Center | $70 | $140 | 10% coinsurance after deductible | 10% coinsurance after deductible | ||
| Laboratory and Pathology | Covered in Full | Covered in Full | Covered in Full | |||
| X-ray | $50 | $55 | $60 | |||
| Advanced Imaging (CT, MRI, etc.) | $75 | 10% coinsurance after deductible | 10% coinsurance after deductible | |||
(1)The lower RRH copays do not apply to tests, treatments or any other services (e.g., allergy shots, chiropractic services, physical therapy, etc.).
| Prescription Drug Coverage | POS A | POS B Only | POS D | |||
| Wegmans | Other Retail(2) | Wegmans | Other Retail(2) | Wegmans | Other Retail(2) | |
| Annual Deductible (individual/family) | Not Applicable | Not Applicable | $1,250 per person, then copays | |||
| Annual Patient Maximum Out-of-Pocket (individual/family) | $2,550/$5,100 | $2,550/$5,100 | $2,650/$5,300 | |||
| Up to 30-Day Supply at Retail | ||||||
| Tier 1: Generic | $15.00 | $17.00 | $15.00 | $17.00 | $25.00 | $30.00 |
| Tier 2: Brand Name-Formulary (preferred) | $35.00 | $40.00 | $35.00 | $40.00 | $70.00 | $80.00 |
| Tier 3: Brand Name-Non-Formulary (preferred) | $50.00 | $60.00 | $50.00 | $60.00 | $130.00 | $150.00 |
| Up to 90-Day Supply at Wegmans or OptumRx Mail Order | ||||||
| Tier 1: Generic | $37.50 | Not Available | $37.50 | Not Available | $62.50 | Not Available |
| Tier 2: Brand Name-Formulary (preferred) | $87.50 | Not Available | $87.50 | Not Available | $175.00 | Not Available |
| Tier 3: Brand Name-Non-Formulary (preferred) | $125.00 | Not Available | $125.00 | Not Available | $325.00 | Not Available |
For a full comparison of the POS plans, please see the current Medical Benefits Comparison Book for specifics.
Prescription Drug Benefits
OptumRx is the pharmacy benefit manager (PBM) which administers RIT’s prescription drug coverage. Under the plan, covered medications can be purchased from a participating retail pharmacy or from OptumRx’s mail pharmacy.
IMPORTANT!
The medical benefit and the prescription drug benefit each have a separate out-of-pocket maximum. This means that medical expenses count only toward the medical plan out-of-pocket maximum, while prescription drug expenses count only toward the prescription drug out-of-pocket maximum.
For POS A, POS B and Blue PPO
| CATEGORY | WEGMANS PHARMACY | OTHER RETAIL(1) | OPTUMRX MAIL | ||
| 30-day supply, no limit on fills | 90-day supply | 30-day supply, up to 3 fills | 30-day supply 4th fill and after(2) | 90-day supply(3) | |
| Tier 1: Generic Drugs | $15.00 | $37.50 | $17.00 | $37.50 | $37.50 |
| Tier 2: Brand Name Formulary Drugs | $35.00 | $87.50 | $40.00 | $87.50 | $87.50 |
| Tier 3: Brand Name Non-Formulary Drugs | $50.00 | $125.00 | $60.00 | $125.00 | $125.00 |
For POS D
| CATEGORY | WEGMANS PHARMACY | OTHER RETAIL(1) | OPTUMRX MAIL | ||
| 30-day supply, no limit on fills | 90-day supply | 30-day supply, up to 3 fills | 30-day supply 4th fill and after(2) | 90-day supply(3) | |
| Annual Deductible - each person must pay $1,250 annual deductible before copay amounts are charged in a plan year | |||||
| Tier 1: Generic Drugs | $25.00 | $62.50 | $30.00 | $62.50 | $62.50 |
| Tier 2: Brand Name Formulary Drugs | $70.00 | $175.00 | $80.00 | $175.00 | $175.00 |
| Tier 3: Brand Name Non-Formulary Drugs | $130.00 | $325.00 | $150.00 | $325.00 | $325.00 |
Wegmans Pharmacies are designated as the “preferred pharmacy” under the plan. Wegmans offers the convenience of a local pharmacy paired with the preferred pricing typically available only at a mail pharmacy. Wegmans also has a free home shipping option available.
Additional Benefits of using Wegmans Pharmacy:
- Lower copay when you purchase your medications at Wegmans than at other retail pharmacies.
- Ability to purchase up to a 90-day supply of your medications at Wegmans, but only up to a 30-day supply at other retail pharmacies.
- Your copay for a 90-day supply at Wegmans is equal to your copay at the mail pharmacy, and lower than the total of three 30-day copays that you would pay at another participating retail pharmacy.
- You may choose to purchase 30-day supplies at Wegmans and your copay will not increase after 3 fills; at other retail pharmacies, your copay for a maintenance medication (those drugs you take for an ongoing medical condition) will increase significantly after 3 fills.
OptumRx has contracted with a broad national network of retail pharmacies. This network includes thousands of pharmacies throughout the United States, including nearly all major retail pharmacy chains, such as CVS and Rite Aid, certain stores containing pharmacies such as Wegmans, Target, Tops, and Wal-Mart, and most smaller, independent pharmacies, including nearly all in the Rochester area. Retail pharmacies in the OptumRx network are referred to as “participating pharmacies.” To locate a participating pharmacy close to your home or other location, you can call OptumRx Member Services or check OptumRx website at www.optumrx.com.
Mail Order Pharmacy
For maintenance medications (prescriptions taken on an ongoing basis), OptumRx’s mail pharmacy offers the convenience of home delivery. Your initial prescription will be delivered within 10 to 14 days of receipt. Refills can be ordered online at OptumRx and are typically delivered within seven to 10 days. Be sure that your physician provides a prescription for a 90-day supply when you are ordering from the mail pharmacy. The mail copay is based upon a 90-day supply, but if your prescription is written for a lesser supply, the same mail copay will apply.
If a particular drug is not available through the mail pharmacy, you will need to fill your prescription at a participating retail pharmacy and pay the applicable retail pharmacy copay.
Optum Rx Specialty Pharmacy
If you are prescribed a specialty medication, you generally must fill it with OptumRx Specialty Pharmacy in order to have coverage. There are a few limited situations in which an exception may be granted in advance by OptumRx and the medication may be purchased at a participating retail pharmacy. Please call OptumRx Customer Service at the dedicated Rochester Institute of Technology toll-free member phone number 1-855-209-1300 (TTY: 711) for more information.
Nonparticipating Retail Pharmacies
When your prescription is filled at a nonparticipating retail pharmacy, your copays are as indicated in the copay charts, plus you will pay any cost difference between the nonparticipating pharmacy’s prescription price and OptumRx’s discounted network prescription price. You will be required to pay the full cost of the prescription at the time you make your purchase; you must then submit a paper claim to OptumRx to receive reimbursement from the plan.
If you take maintenance medications (those you take for an ongoing medical condition), there is a significant financial incentive to purchase them at Wegmans, our preferred retail pharmacy, or through OptumRx’s mail pharmacy.
On the 4th fill (original plus 3 refills) of a maintenance prescription filled at a retail pharmacy (other than Wegmans), your copay for a 30-day supply will be equal to the copay for a 90-day supply of the medication if you ordered it from OptumRx’s mail pharmacy or purchased it at Wegmans. This will result in greatly increased copays if you continue to fill your maintenance medications at a retail pharmacy other than Wegmans beyond the 3rd fill.
This higher copay does not apply to acute care drugs such as antibiotics – your copays for such medications purchased at a retail pharmacy will not change. Also, certain medications are not available from OptumRx’s mail pharmacy, such as certain controlled substances; the higher copay will also not apply in these situations. The rest of the cost of your drugs will be paid by the prescription drug plan, except as described below:
- In cases of selected brand name drugs where an FDA-approved generic is available, your benefit will be based on the generic drug’s cost. If you or your doctor chooses the brand name drug, regardless of the reason, you will be required to pay the difference in cost between the brand-name drug and the generic, in addition to the applicable copay.
- If you purchase your medication at a nonparticipating pharmacy, you will be required to pay the full cost at the pharmacy. You can then file a claim for reimbursement (described in the section “Claims and Payment of Benefits”) with OptumRx. Your cost will be the retail copay you would have paid at a participating pharmacy (other than Wegmans), plus any additional amount charged by the nonparticipating pharmacy above the amount the drug would have cost at a participating retail pharmacy.
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Program |
Description |
| Prior Authorization | Certain prescriptions require additional information from your physician before the plan will cover it. |
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Preferred Drug Step Therapy |
Preferred Drug Step Therapy is ensure that a person has tried a particular preferred drug or drugs in a specific therapeutic category before the Plan will cover a more expensive drug in that category. It is often common for physicians to prescribe brand name drugs with which they are familiar, but that may not always be the most effective and cost effective choice of therapy. Only selected categories that have clinically accepted substitutes, determined by OptumRx clinicians, are part of the PDST program. When your physician prescribes a brand name drug that is part of the PDST program, the Plan will only cover it if you have tried the clinically accepted alternative drug(s) and either:
If this information is in OptumRx’s records, the brand name drug will be approved without any intervention needed by your physician. If this information is not in OptumRx’s records (for instance, if you tried the other medication before you were covered by the Plan), the drug will not be covered without a coverage review and approval by OptumRx. |
| Quantity Limits | Certain medications, there are limits on the quantity that will be covered. |
| Refill Limits |
For refills:
If you will be traveling and need to refill your prescription early, let the pharmacist know and request that he or she call OptumRx for a “vacation override.” |
Rochester Regional Health (RRH)
Located right on the RIT Henrietta campus, Family Medicine at RIT provides complete medical care in a convenient location. All RIT employees and their family members are welcome at this practice. More information about this location can be found at Rochester Regional Family Medicine at RIT.
The practice is in the Clinical Health Sciences Center located at the north end of Louise Slaughter Hall. The office hours of operation are Monday through Friday, 8:00AM to 5:00 PM.
Adjacent to the practice is the Rochester Regional Health Outpatient Lab, where you can have blood drawn or provide a urine sample. The hours of operation are Monday through Friday 7:00 AM to 4:00 PM (closed for lunch 12-1 PM). The lab is open to the public and no appointment is required, but you will need to bring a lab request from your medical provider.
In support of the strategic alliance between RIT and Rochester Regional Health (RRH), there are two ways for medical plan participants to save money on their medical care:
- If a POS plan member has an appointment at Rochester Regional Family Medicine at RIT, they will have a lower $20 copay for the PCP
- There is an “RRH Copay Option” within our point of service medical plans. Under this option, there is a slightly lower copay when you obtain the following medical services from the Domestic Network of RRH providers:
- office visit to primary care physician (PCP)
- office visit to specialists
- emergency room visits
- Under POS A only, there is a lower copay for Inpatient Hospitalization and Outpatient Services.
- The lower copays do not apply to tests, treatments or any other services (e.g., allergy shots, chiropractic services, physical therapy, x-rays, etc.). These lower copays are outlined.
See the current Domestic Network listing for participating providers.
Additional Resources
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Key Terms |
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Copay |
Set amount the patient pays for a service, regardless of the total cost of the service.
Example: you pay a $40 copay for an office visit, whether you see the doctor for 5 minutes or 30 minutes. |
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Deductible |
Annual amount the patient must pay before the plan begins to pay.
Example: you pay the first $250 for a service before the plan will pay anything. |
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Coinsurance |
Percentage of eligible expenses the patient pays.
Example: you pay 10% of the cost for a covered service and the plan pays 90% of the cost for a covered service. |
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Out of Pocket Maximum (OOP) |
Maximum amount the patient will pay in the calendar year for covered services. If the OOP maximum is reached, the plan will pay 100% for covered services for the remainder of the calendar year.
Example: if the medical OOP maximum is $5,050, once you have paid $5,050 for medical services, the plan will pay 100% of covered medical services for the remainder of the calendar year. |
Example of how a deductible and coinsurance works:
- Sam is enrolled in POS B, individual coverage, which has a deductible and coinsurance for inpatient hospitalization
- In January, Sam has an inpatient hospital stay of 3 days
- The total cost of the stay is $20,000
- Sam pays the first $250 to meet the deductible
- This leaves a balance of $19,750
- Sam pays 10% coinsurance on the remaining $19,750, or $1,975
- Sam's total cost for the hospitalization is $2,225 ($250 + $1,975)
- The plan pays $17,775
- Sam pays the first $250 to meet the deductible
When choosing which medical plan that is right for you and your family...
- It's not just about the premium you pay out of your paycheck - you need to consider your estimated out of pocket costs as well
- Generally, the higher the premium contribution, the lower the out of pocket cost (will not apply for all services).
- The plan with the highest premium contribution may not be the best plan for you. If you rarely go to the doctor and you do not take any medications or take only an inexpensive generic medication(s), you might not need to pay for the plan with the richest benefits.
- The plan with the lowest premium contribution may not be the least expensive plan for you overall - you will likely have higher out of pocket costs.
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POS Plans Similarities |
POS Plans Differences |
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As part of the Federal Consolidated Appropriations Act (CAA), new Transparency in Coverage rules have been established by the Centers for Medicare & Medicaid Services (CMS), including a multi-year initiative that requires health plans to share contracted prices for all health care items and services. The first phase of these requirements begins July 1, 2022.
Excellus BlueCross BlueShield (BCBS) has provided the link below where you can find the following information:
- In-network provider contracted rates for items and services
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Out-of-network allowed amounts and billed charges for items and services
Please note that the link below is to a machine-readable file and is designed for a machine (i.e., computer) to read and will not be user-friendly for members. The best user experience for Excellus BCBS members will be to login to their online account (www.excellusbcbs.com) to access the cost estimation tool where you will be able to see both the cost of services (“contracted rates”) and how your own medical plan benefits will apply to those rates.
Excellus Online Member Link:
https://www.excellusbcbs.com/transparency-coverage-mrf
If you have any questions, please contact Excellus directly at 877-253-4797.