Pharmacy plan

Mail-order pharmacy

You may fill your prescription via the MedImpact mail order service. You must submit a 90-day written prescription along with two copayments using the mail service prescription order process
HSA members: Available only when co-payments apply. 

Other forms and services

  • Prescription mail order fax form
  • Prescription reimbursement form.

Retail pharmacy

If you elect and enroll in any medical plan, MedImpact will be the network of drugstores, supermarkets and discount stores for pharmacy benefits to fill prescriptions at a network pharmacy. You will be required to present your medical card in order to have prescriptions filled. The cost of prescriptions filled out-of-network will not be reimbursed. 

HSA members: Preventive prescriptions have a copay. Nonpreventive prescriptions are subject to a deductible.  


$15 retail, 30-day supply

$37.50 retail, 90-day supply

$30 mail-order, 90-day supply 

Preferred formulary

$40 retail, 30 day supply

$100 retail, 90 day supply

$80 mail-order, 90 day supply

Nonpreferred, nonformulary

$60 retail, 30 day supply

$150 retail, 90 day supply 

$120 mail-order, 90 day supply

Note: If your doctor prescribes a brand name drug and indicates that the generic equivalent is acceptable, but you decline the generic, you will be responsible for the copay, plus the retail cost of the brand name minus the retail cost of the generic. 

Preventive prescriptions

Some preventive prescriptions will be covered at 100% for the Triple Choice Plan. The HSA will have a copay associated with preventive drugs. Visit MedImpact for details. 

Limited prescription drug coverage

Prescription drug coverage will generally be limited to medications that do not have an equally effective over-the-counter substitute. If traveling outside of the U.S., pharmacy benefit coverage applies only to emergencies on a reimbursement basis.

Noncovered drugs 

Certain medications are not covered as part of the plan. If you find such a drug has been prescribed for you, discuss alternative treatment with your doctor. 


The formulary is the list of medications chosen by a committee of doctors and pharmacists to help you maximize the value of your prescription benefit. Formulary changes can occur during the plan year. Medications that no longer offer the best therapeutic value are deleted from the formulary. Ask your pharmacist to verify the current copay amount when your prescription is filled. Sharing this information with your doctor helps ensure you get the best value, which saves you and your plan money.

  • Preferred Drug List has commonly prescribed medications within select classes of drugs covered on your formulary. The formulary is updated regularly and is subject to change without advance notice.
  • Specialty Drug List is monitored to ensure that employees receive the most clinically effective medications at the lowest cost. The Specialty Drug List is updated regularly and is subject to change without advance notice. All Specialty Drug List medications are provided through a MedImpact Direct Specialty network pharmacy. Members may enroll in services by calling 877-391-1103.
  • Essential Health Benefits List, ACA is in compliance with healthcare reform requirements under the Affordable Care Act, certain preventive medications are covered at zero-copay under the pharmacy benefit as needed. State-specific requirements may vary.

Medication prior authorization may require clinical approval before it can be filled, even with a valid prescription. These prescriptions may be limited to quantity, frequency, dosage or may have age restrictions. You, your local pharmacy, or your physician may initiate the authorization process by calling MedImpact at 888-648-6769. 

Step therapy program promotes the use of safe, cost-effective and clinically appropriate medications. Members use a safe and equally effective generic, alternative medication before a brand-name medication is covered. Refer to the Formulary Lookup in the MedImpact member portal for a complete list of drugs under this program.

MedImpact member portal benefits

  • Determine drug coverage and obtain a cost estimate for a selected medication. 
  • Find a pharmacy without registration. Select General Pharmacy Locator. 
  • Health tips plus info on diseases and health conditions. 
  • Personal Health Rx® – Print your prescription history for a physician visit or tax reporting. 
  • Pharmacy locator – Find a participating pharmacy near you. 
  • Research more than 17,000 medications. 
  • View your current copayment amounts and other pharmacy benefit considerations. 

Book traversal links for Pharmacy plan