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.