Understanding Your Prescription Drug Coverage

In order to provide high quality, affordable prescription drug coverage for you and your family, MDwise Marketplace uses a company called MedImpact to ensure you get the most from your benefits. MedImpact manages a list of covered drugs called a formulary. This formulary may be different than your previous prescription coverage program. It is important that you understand what medications are covered and what it will mean for you and your family.

Medications are organized into five tiers:
 
  Status Definition
Tier 1 Tier 1 Drugs
Tier 2 Tier 2 Drugs
Tier 3 Tier 3 Drugs
Tier 4 Tier 4 Drugs
Tier 5 Tier 5 Drugs
Non-Formulary Non-Formulary

Each tier has a different copay or coinsurance requirement. Tier 1 has the lowest out-of-pocket cost. Tier 4 has the highest. Often medications that are listed on a higher tier have a therapeutic equivalent. A therapeutic equivalent is a drug that has essentially the same effect in the treatment of a condition as one or more other drugs. The therapeutic equivalent may have a lower copay. For example, if the drug you are currently taking is Tier 3, you could save money by working with your provider to find a therapeutically equivalent Tier 1 drug.

Certain medications or supplies listed as non-covered may be available if medical necessity is determined after clinical review. Please contact your prescribing doctor to request that your doctor submit a prior authorization request to MedImpact for non-covered medications or supplies. Prior authorization forms are available for your doctor on the pharmacy forms page.

The benefit plan that you selected when signing up for MDwise Marketplace determines the amount of cost sharing for medications. The cost sharing differs depending on your plan choice and the tier of the medication. Please see the charts below for more information on your cost sharing responsibility for each prescription tier based on your benefit plan. Tier 1, Tier 2, and Tier 5 medication cost sharing applies before you have met your deductible. But, Tier 3 and Tier 4 cost sharing applies after you have met your deductible.

2017 Bronze Plans
Tier Bronze Basic Bronze Plus Bronze Plus
with Adult Vision
Tier 1 $70 $55 $55
Tier 2 $140 $110 $110
Tier 3 40% 40% 40%
Tier 4 40% 40% 40%
Tier 5 $0 $0 $0

2017 Silver Basic Plans

Tier

Silver

Basic

Silver

Basic 73

Silver

Basic 87

Silver 

Basic 94

Tier 1  $20 $15 $10 $10
Tier 2  $50 $25 $15 $15
Tier 3 15% 15% 10% 0%
Tier 4 15% 15% 10% 0%
Tier 5 $0 $0 $0 $0

2017 Silver Plus Plans
Tier

Silver

Plus

Silver

Plus 73

Silver

Plus 87

Silver 

Plus 94

Tier 1  $20 $15 $15 $10
Tier 2  $45 $40 $30 $15
Tier 3 15% 15% 10% 0%
Tier 4 15% 15% 10% 0%
Tier 5 $0 $0 $0 $0


2017 Silver Plus with Adult Vision

Tier

Silver Plus
With
Adult Vision

Silver

Plus 73 with 
Adult Vison

Silver

Plus 87 with
Adult Vison

Silver 

Plus 94 with 
Adult Vision

Tier 1  $20 $15 $15 $10
Tier 2  $45 $40 $30 $15
Tier 3 15% 15% 10% 0%
Tier 4 15% 15% 10% 0%
Tier 5 $0 $0 $0 $0

2017 Silver Coinsurance Plans
Tier

Silver
Coinsurance

Silver

Coinsurance
Plus 73

Silver
Coinsurance
Plus 87

Silver 

Coinsurance
Plus 94

Tier 1  $30 $20 $10 $5
Tier 2  $55 $45 $15 $10
Tier 3 15% 15% 10% 0%
Tier 4 15% 15% 10% 0%
Tier 5 $0 $0 $0 $0
 

2017 Gold Plans

Tier Gold Plus Plans
with Adult Vision
Tier 1 $10
Tier 2 $35
Tier 3 10%
Tier 4 10%
Tier 5 $0


2017 Zero Cost Share Plans

Tier Zero Cost Share
Tier 1 $0
Tier 2 $0
Tier 3 0%
Tier 4 0%
Tier 5 $0


My medication isn’t on the formulary. What do I do?

If you looked on the formulary and didn’t find your prescriptions OR see that your prescriptions require a prior authorization, please contact your doctor to discuss the situation. Your doctor may need to work with you and MedImpact to find a therapeutic equivalent medication or request prior authorization for you to continue on your current therapy. You may be asked to switch to a therapeutic equivalent medication. If this is not an option, you will have to pay coinsurance for a non-preferred medication.
 

What is prior authorization?

Prior authorization, also known a PA, is a process in which your doctor submits clinical information about your health condition to MedImpact. This clinical information is intended to justify the reason you need a non-preferred medication. At MedImpact, a clinical team will review the request and make a decision about the treatment requested. If you or your doctors do not agree with the decision, you will have the right to appeal the decision.

Certain medications may be available for a 90-day supply. Please contact MedImpact for a listing of these medications at 844.336.2684.
 

My doctor told me that I have to go through “Step Therapy” before my medication can be approved. What does this mean?

In some cases, our plan requires you to first try certain medications to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, our Plan will then cover Drug B.
 

What does it mean when there is a quantity limit?

A quantity limit is when there is a limit to the amount of a medication that our plan will cover. This could refer to how much per month or how much per lifetime. For example, drug A is only to be taken two time daily as more could be harmful; our plan could set a quantity limit for #60 tablets in 30 days as a safety measure for you the member. As another example, chemotherapy drug B has a lifetime limit of X as more could be very harmful. Our plan could set a quantity limit for X per member’s lifetime as a safety measure.
 

What is a network pharmacy?

A network pharmacy is a pharmacy that is covered by your plan and it is where you can have your prescriptions filled. MedImpact has a network of participating pharmacies that can provide services to MDwise Marketplace members. If you receive medications from a non-network pharmacy, you will be responsible for the full cost of the medication. Find a pharmacy in the network that is closest to you.


What is mail order pharmacy?

Through mail order pharmacy, you are able to receive a 90-day supply of some of your medications. Your physician will need to submit prescriptions to Postal Prescription Solutions (PPS) to request a 90-day supply. Certain medications are not eligible for a 90-day supply. You or your provider can check this out by contacting PPS customer service at 800.552.6694.


How can I view my prescription drug claims?

You can log in to your myMDwise account to view your prescription drug claims. Once you log in, you can see detailed information about your prescription drug claims, including:
  • How much you paid
  • How much the plan paid
  • What the drug is used for
  • Potential side-effects
  • Potential drug interactions