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 Mountain Health Co-Op members with Individual 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.

Your pharmacy benefit has four drug tiers. These tiers determine your out-of-pocket responsibility and correspond to the copay 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 preferred specialty drugs (most require prior authorization and must be filled at the Plan’s designated Specialty Pharmacy).

These medications are indicated by the following symbols in the online formulary.

Drugs listed in our $0 Prescription List  are available to members no out-of-pocket cost.

Prior authorization helps encourage safe, cost-effective use of prescription drugs by requiring a request form from your physician before the drug will be covered. If PA appears in the Requirements column, the drug requires prior authorization.

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 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 a formulary exception request to us. 

Specialty medications (identified with an “S” in a red-orange circle) treat complex or chronic conditions, such as multiple sclerosis, hepatitis C, and rheumatoid arthritis. They may be taken by mouth, injection, or infusion and often need special handling, so they are not stocked at regular retail pharmacies. In most cases, they must be filled at a designated specialty pharmacy.

Coverage

• Medications given by a healthcare professional are usually covered under your medical benefit.
• Self-administered specialty drugs are covered under your pharmacy benefit as Tier 4 medications.

 How to Access Specialty Medications

Your plan generally requires self-administered specialty drugs to be filled through Mountain Health Co-Op’s preferred specialty pharmacy or another in-network one. Many Tier 4 drugs also need prior authorization—your provider can request it using our form or by calling RealRx Pharmacy Customer Service at 855-885-7695.

For your specific copay or deductible, check your Plan Documents in the Member Portal.