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href="/insurance-and-forms">Insurance and Forms</a> > <span class="breadcrumb-page-title">Prescription Plan</span></div></div></div> <h1 class="title" id="page-title">Prescription Plan</h1> <div class="content-top"> </div> <div id="main-wrapper"> <div id="main" class="clearfix"> <div id="content" class="column"> <div class="inside"> <a id="main-content"></a> <div class="tabs"></div> <div class="region region-content"> <div id="block-system-main" class="block block-system"> <div class="content"> <div id="node-241" class="node node-page slider-secondary clearfix" about="/insurance/prescription-plan" typeof="sioc:Item foaf:Document"> <span property="dc:title" content="Prescription Plan" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="content"> <div class="field field-name-field-body field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="par-biggest">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.</p> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p><label for="accordion-1">Prescription and Pharmacy</label></p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <table border="0" cellpadding="0" cellspacing="0" style="overflow: scroll;" tabindex="0" width="100%"> <tbody> <tr> <td style="width: 85px;">Billing</td> <td style="width: 312px;">Optum Rx<br /> PO Box 968022<br /> Schaumburg, IL 60196-8022<br /> 1-844-265-1879</td> </tr> <tr> <td style="width: 85px;">Member ID</td> <td style="width: 312px;">Call: 1-866-940-8306</td> </tr> <tr> <td style="width: 85px;"> <p>Rx Group #</p> <p>BIN Number</p> </td> <td style="width: 312px;"> <p>UCSHIP</p> <p>610011</p> </td> </tr> <tr> <td style="width: 85px;">Network</td> <td style="width: 312px;"> <p>Optum Rx<br /> <em>Includes CVS, Safeway, Parnassus Heights (PH) Pharmacy and Walgreens.</em><br /> Call: 1-844-265-1879</p> <a href="https://www.optumrx.com/content/rxmember/default/en_us/angular-free/optumrx/landing.html" target="_blank">https://www.optumrx.com/content/rxmember/default/en_us/angular-free/optumrx/landing.html</a></td> </tr> </tbody> </table> </div> </div> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p>Benefit Summary</p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <table border="1" cellpadding="1" cellspacing="1" style="overflow: scroll;" tabindex="0" width="200"> <tbody> <tr> <td> </td> <td>IN-NETWORK</td> <td>OUT-OF-NETWORK</td> </tr> <tr> <td>Generic</td> <td>$5 co-pay</td> <td>$5, then 60% of billed charges</td> </tr> <tr> <td>Brand</td> <td>$25 co-pay</td> <td>$25, then 60% of billed charges</td> </tr> <tr> <td>Non-formulary Brand</td> <td>$40 co-pay</td> <td>$40, then 60% of billed charges</td> </tr> <tr> <td>Mail Order (90 day supply)</td> <td>$15 generic<br /> $75 brand<br /> $120 non-formulary brand</td> <td>Not determined at this time.</td> </tr> <tr> <td>Prescription Benefit Year Maximum</td> <td>unlimited</td> <td>unlimited</td> </tr> </tbody> </table> </div> </div> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p><label for="accordion-3">Prescription Reimbursement</label></p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <p>Students can get partial reimbursement for medication obtained outside of network pharmacies. Students must mail a <a href="https://studentmentalhealth.ucsf.edu/insurance/forms-brochures#rx">Prescription Claim Form</a> 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.</p> </div> </div> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p><label for="accordion-4">Mail Order</label></p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <p>To receive your prescriptions via Mail Order with free standard shipping, please complete the <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/ORX5633S-CTRX_160329_FORM_NRX0002_Kansas_FINAL.pdf">OptumRx Home Delivery Form</a> and mail or fax with your maintenance prescription written for a 90-day supply. You also have the option to <a href="https://www.optumrx.com/content/rxmember/default/en_us/angular-free/optumrx/landing.html" target="_blank">log onto the Optum Rx website </a>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.</p> <p>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.</p> <p>OptumRx Home Delivery<br /> PO Box 2975<br /> Mission, KS 66201<br /> Tel: 1-888-637-5121<br /> Fax: 1-888-637-5191</p> </div> </div> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p><label for="accordion-5">Out-of-California Network</label></p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <p>When out-of-California, students can locate a participating pharmacy by calling 1-844-265-1879. If students cannot locate a participating pharmacy, they can pay for the drug and submit a <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/ORX%20DMR%20Standard%20Commercial%20Schaumburg%20081415.pdf">Prescription Claim Form</a> to the claims administrators.</p> </div> </div> <div class="collapse-item"> <div aria-expanded="false" class="header-text" role="button" tabindex="0"> <p><label for="accordion-6">Formulary</label></p> </div> <div aria-hidden="true" class="content-text" role="region" tabindex="-1"> <p>Download the <a href="https://studentmentalhealth.ucsf.edu/insurance/forms-brochures#rx" target="_blank">Approved Formulary Drug List</a>.</p> <p>Download the <a href="https://studentmentalhealth.ucsf.edu/insurance/forms-brochures#rx" target="_blank">Formulary Exclusion List</a>.</p> </div> </div> </div></div></div> </div> </div> </div> </div> </div> </div> </div> <div id="sidebar" class="column"> <div class="sidebar_top"> <div class="region region-sidebar-top"> <div 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id="footer"> <div class="section"> <div class="region region-footer"> <div id="block-block-16" class="block block-block"> <div class="content"> <p><strong>UCSF Student Mental Health and Wellbeing</strong></p> <div aria-label="Student Health and Counseling Contact Information Footer" class="wysiwyg_threecols layout--33-33-33" role="region"> <div class="wysiwyg_threecols--first bg--undefined bg--transparent"> <p><strong>Parnassus</strong><br /> 500 Parnassus Ave.,<br /> level P8, room 005<br /> San Francisco, CA 94143<br /> <b>Telephone:</b> (415) 476-1281<br /> <strong>email: </strong><a href="/cdn-cgi/l/email-protection#4c3f21243b0c392f3f2a62292839"><span class="__cf_email__" data-cfemail="0a7967627d4a7f69796c246f6e7f">[email protected]</span></a></p> <p> </p> </div> <div class="wysiwyg_threecols--second bg--undefined bg--transparent"> <p><strong>Mission Bay</strong><br /> 1675 Owens St.,<br /> Rutter Center, 3rd Floor, room 330<br /> San Francisco, CA 94158<br /> 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