$0 out-of-pocket drugs & supplies
With our plans, you won’t need to ration prescriptions or supplies.
Our $0 out-of-pocket Prescription List provides coverage for specific drugs for members with group or individual plans.
What are the $0 Drug Categories?
Do you take medications in one of the categories listed below? If so, these are zero cost to Members.
$0 Drug Categories:
- Anticoagulant Medications
- Antidepressant Medications
- Blood Glucose Meter
- Bone Medications
- Cardiovascular Medications
- Cholesterol Medications
- Continuous Glucose Monitor
- Diabetic Medications
- Diabetic Supplies
- Diabetic Test Strips
- Respiratory Medications
No need to ration supplies
Many insulins are available for $0 along with supplies and glucose monitoring.
How can I tell if my medication qualifies?
Look for the green ‘VAL’ label in the online search directories to learn if your meds are considered a Value Preventive Drug and qualify for $0 out-of-pocket costs.
Or find your medication in the PDFs listed below.
By putting our members first, you save time and money with the CO-OP.
Prior Authorization Forms
Help with Prior Authorization
The best way to request prior authorization is by submitting a completed Prior Authorization form through the MyCare portal.
Urgent requests: 72 hours.
Standard requests: within 14 calendar days.
All required documentation must be received prior to processing.
“Urgent” is defined as:
Medical services that are needed in a timely or urgent manner that would subject the member to adverse health consequences without the care or treatment requested. Mountain Health Co-Op reserves the right to classify Urgent requests as standard requests when this definition is not met.
To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation.
Failure to submit required documentation may result in processing delays, the inability to establish medical necessity, and possibly a denial.
Submit all relevant documentation through the MyCare portal.
Inpatient Admissions Documentation Needed:
- Admitting Orders
- H&P
- ED documentation
- Labs
- Imaging Results
- Medications
Procedure/Imaging Clinical Documentation Needed:
- physician notes
- physical statement
- detailed physical exam on affected site
- radiological findings
- lab results
- specific indication and other pertinent information related to the request
- NSAID usage
- physical therapy and all other medical modalities tried – start and end time and the effectiveness of the medication, other modalities, and PT services (for imaging request)
Power or Custom Wheelchair Documentation Needed:
- current wheelchair type
- date of purchase and purchaser (i.e. insurance; private)
- clinical evaluation by patient’s PCP addressing ambulatory ability
- prognosis (in LOMN form)
- Wheelchair evaluation by PT/OT within 6 months for clients 21 and older; Shriners and primary Children’s are affiliates within 3 months for under 21
- Patient skills check list for power chair
- barriers to transport
- use/accessibility of residents have been addressed
- repair history of current wheelchair (if applicable)
Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)?
Please only use the Retroactive Prior Authorization Form in response to 252 and/or M127 denial codes.
Formulary Change Notices
What is a Specialty Medication?
Specialty medications are generally prescribed to treat complex and/or chronic conditions, such as multiple sclerosis, hepatitis C, and rheumatoid arthritis.
Specialty medications that require professional services for administration are usually covered under your medical benefit plan.
Look for these labels in the search directories to determine your medication’s requirements.
Access Plans
Your plan may require you to get self-administered specialty drugs through Mountain Health CO-OP’s preferred specialty pharmacy or another in-network specialty pharmacy.
Order Prescriptions Online
Your meds delivered.
Use the Rx information on your member benefits card to set up a profile with Birdi, our mail order pharmacy, and have your medications delivered to you.
Pharmacy Mail Order – Instructions
- 24/7 Customer Service
- Online Member Tools
- Expert Medication Support
- Specialty Pharmacy Services
Need help with your medications?
We partner with the experienced team at RealRx to give you the support you need. Whether you have questions about your medications or need help filling a prescription, they’re available to help.
RealRx Service Team
855-885-7695
Email
[email protected]
Drug List Abbreviations and Terms
Specialty medications are generally prescribed to treat complex and/or chronic conditions, such as multiple sclerosis, hepatitis C and rheumatoid arthritis.
These medications may be taken by mouth, injection or infusion and have special handling or storage requirements and may not be stocked by retail pharmacies.
Specialty medications that require professional services for administration are usually covered under your medical benefit plan.
Coverage for self-administered specialty medications is provided through your pharmacy benefit plan.
How to access
Your plan may require you to get self-administered specialty drugs through Mountain Health CO-OP’s preferred specialty pharmacy or another in-network specialty pharmacy.
Specialty medications are designated as Tier 4 medications in Mountain Health CO-OP’S list of covered drugs (formulary). Certain Tier 4 specialty medications require prior authorization, and your provider may submit a coverage request by using our existing medication prior authorization form or by calling UUHP Pharmacy Customer Service at 855‐885‐7695
Value Preventive Drugs are also referred to as $0 out-of-pocket drugs.
These medications are covered even before you meet your deductible or annual out-of-pocket expenses because they are considered preventive.
Preventive health care refers to proactive measures taken to maintain and improve an individual’s overall well-being and prevent the onset of illness or disease.
This means members won’t pay any money out-of-pocket for medications listed in our value-based preventive drug list or labeled with ‘Value Preventive’ on the search tool.
Mountain Health Co-Op has expanded coverage of these medications beyond what is covered at no cost-share ($0 out-of-pocket) under the Affordable Care Act (ACA).
It is available to ALL Mountain Health CO-OP plan members, including those in Individual and Family Plans, Small Group Employer Plans, and Large Group Employer Plans.
However, your plan may require you to get Value Preventive Drugs via an in-network pharmacy. Search now.
Your pharmacy benefit has four drug tiers and an additional category for no cost Preventive drugs. These tiers determine your out-of-pocket responsibility and correspond to the copays and/or coinsurance shown on your benefit summary. Tier 1 drugs are preferred generics with the lowest copay. Tier 2 drugs are non-preferred generics and preferred brands with a mid-range copay. Tier 3 drugs are non-preferred brands with a high copay. Tier 4 drugs are specialty drugs (most require prior authorization and must be filled at the Plan’s designated Specialty Pharmacy).
Drugs listed in our additional Preventive Drug Benefit have no member cost share, even before deductible.
Pre-authorization helps encourage safe, cost-effective use of prescription drugs by requiring a “prior authorization” request from your physician before the drug will be covered. If PA appears in the Requirements column, the drug requires pre-authorization from your physician before the drug will be covered.
QL stands for quantity limits. If QL appears in the requirements column, the drug may be covered by your plan, but only up to a certain quantity or limit. If you need quantities higher than the limit shown, have your provider fax a preauthorization request to us.
SP stands for specialty or biotech drug. In most cases, specialty drugs are required to be filled at a designated specialty pharmacy. Check your member handbook or Summary of Benefits to find the specialty drug copay amount or deductible amount.
SP stands for Step Therapy, a program that requires you to try a lower-cost alternative medication (“Step 1 Drugs”) before using the more expensive (“Step 2”) medication. If it is medically necessary for you to use a Step 2 medication as initial therapy, your provider can submit an exception request to us.
All Pharmacy Downloadable PDFs
