Your Prescription Benefits Handbook
Summary of State of Maryland Prescription Benefits available through
MedImpact Healthcare Systems, Inc.
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Welcome to MedImpact
MedImpact Healthcare Systems, Inc. (MedImpact), the Pharmacy Benefit Manager (PBM), manages your
prescription drug benefit under a contract with the State of Maryland. MedImpact maintains a preferred drug list,
manages a network of retail pharmacies, and operates Mail Service and Specialty Drug pharmacies. In consultation
with the plan, MedImpact Healthcare Systems, Inc. also provides services to promote the appropriate use of
pharmacy benefits, such as review for possible excessive use, recognized and recommended dosage regimens,
drug interactions and other safety measures. Employees and dependents covered by the State of Maryland
prescription drug benefit can use either retail pharmacies or the MedImpact Direct Mail Program.
For additional plan information, please refer to the Evidence of Coverage document located on the DBM Health
Benefits Prescription Drug Coverage webpage.
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Understanding your benefits
The amount you pay for your covered medications – also known as your copayment*—will depend on two factors:
• Whether your prescription is filled as a generic, a brand-name or specialty medication
• Where your prescription is filled (at a participating local pharmacy, at an out-of-network** local pharmacy
or through MedImpact Direct Mail Program)
Employees and Non-Medicare Retirees
Type of Medication Up to 45-Day Supply (1 copayment) 46-90 Day Supply (2 copayments)
Generics $10 $20
Preferred Brands $25 $50
Other Brands $40 $80
Out-of-Pocket Maximum Active Employees Non-Medicare Retirees
Single only coverage $1,000 $1,500
Family coverage $1,500 $2,000
SLEOLA Plan Design – Active Employees Only
Type of Medication Up to 45-Day Supply (1 copayment) 46-90 Day Supply (2 copayments)
Generics $5 $10
Preferred Brands $15 $30
Other Brands $25 $50
Out-of-Pocket Maximum
All Coverage Tiers $700 -
SLEOLA = State Law Enforcement Officers Labor Alliance, State of Maryland
Out-of-pocket maximums
Once your pharmacy out-of-pocket expense reaches the levels specified below, the plan will pay covered charges
at 100% for the remainder of the calendar year.
• Active Employees: $1,000 Individual | $1,500 Family
• Non-Medicare Retirees: $1,500 Individual | $2,000 Family
• SLEOLA: $700 all coverage levels
Additional costs for purchasing a brand-name medication when a generic equivalent is available (ancillary charges)
do not apply to the out-of-pocket maximum. These out-of-pocket maximums are separate from out-of-pocket
maximums for your medical plan. Refer to your medical plan summary plan description for information on your
medical out-of-pocket maximums.
Notes for Non-SLEOLA and SLEOLA plan designs: 1. If you receive a brand-name medication when a generic is available, you will pay the
brand copayment plus the difference in cost between the generic and brand-name medication. 2. Some specialty drugs require limited distribution
and must be filled through a specialty pharmacy. 3. Specialty drugs are limited to a 30-day supply.
*If the cost of your medication is less than the minimum copayment, you will pay the lower amount.
**Refer to page 6 for instructions when using out-of-network pharmacies.
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Affordable Care Act (ACA)
Your health plan offers certain preventive service benefits at no cost to you, which means you do not have to pay
a copay. These no-cost benefits are part of the Affordable Care Act and include:
• Medicine and supplements to prevent certain health conditions for adults, women and children
• Medicine and products for quitting smoking or chewing tobacco (tobacco cessation)
• Medicine used prior to screenings for certain health conditions in adults
• Contraceptives for women
MedImpact Healthcare Systems, Inc. works with your health plan to provide these benefits. For additional details,
refer to MedImpact State of Maryland Website.
State of Maryland Zero Copayment for Generics Copayments reduced to $0 for the following generic
Program drug classes
Drug Class Generic Drug Examples
HMG CoA Reductase Inhibitors (Statins) Simvastatin, pravastatin
Angiotensin Converting Enzyme Inhibitors Lisinopril, lisinopril/HCTZ, enalapril, enalapril/HCTZf
PPIs Omeprazole
Inhaled Corticosteroids Budesonide
Selective Serotonin Reuptake Inhibitors Fluoxetine, paroxetine, sertraline, citalopram
*This list is not comprehensive and is subject to change without notice to accommodate new prescription medications and to
reflect the most current medical literature.
Generics Preferred Program (Automatic Generic Substitution)
If you want to lower your out-of-pocket costs, ask your doctor whether a generic medication is available and right
for you. With a generic medication, you get the same high-quality, effective treatment that you get with its brand-
name counterpart—without the high cost. FDA-approved generic equivalent medications contain the same active
ingredients and are subject to the same rigid standards established by the FDA for quality, strength and purity, as
their brand-name counterparts. To help manage the cost of prescription benefits, the plan includes an automatic
generic substitution feature.
How does the “generics preferred program” work? When your doctor prescribes a brand-name medication and a
generic substitute is available, you will automatically receive the generic unless:
• Your doctor writes “dispense as written” (DAW) on the prescription; or
• You request the brand-name medication at the time you fill your prescription
If you choose generic medications, you get high-quality, effective medication at the lowest cost. Your copayment
for the generic medication will be less than the copayment for the brand-name medication. If a generic is available,
but you or your doctor request the brand-name medication, you will pay the brand copayment PLUS the full
difference in cost between the brand-name medication and the generic equivalent. Please note: if your doctor
requests you take the brand-name medication due to medical necessity, please call MedImpact at 1-844- 348-8508.
Specialty Guideline Management (SGM)
Your plan has guidelines in place to ensure the appropriate use of specialty medications. Many specialty
medications are biotech drugs that are expensive or have limited access, complicated treatment regimens,
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compliance issues, special storage requirements and/or manufacturer reporting requirements. If your doctor
prescribes a specialty medication, it will be automatically reviewed for any additional requirements (such as step
therapy, prior authorization, and quantity or dosage limits). Specialty medications will be limited to a maximum 30-
day supply per prescription fill. This list may change over time as new prescription medications become available.
Examples of Conditions Needing Specialty Drugs
Auto-Immune Diseases (E.g., Rheumatoid Arthritis, Psoriasis & Inflammatory Bowel Disease)
Multiple Sclerosis
Blood Disorder
Cancer
Hepatitis C
Osteoporosis
Growth Hormones
Excluded
• Anorectics (any drug used for the purpose of weight loss)
• Aerochamber, Aerochamber with Mask and Nebulizer Masks and all other medical supplies
• Over-the-counter vitamins except those covered under the Affordable Health Care Act
• Bulk Compounding Ingredients, kits, high-cost bases
• Medications used for cosmetic purposes only such as hair growth stimulants
• Experimental/Investigative Drugs - Homeopathic Products
• Worker’s Compensation Claims
• Unapproved Products
How to use your plan
There are several ways to fill your prescriptions depending on your needs:
For medications taken for a short time
For medications you take for a short time, such as antibiotics for strep throat or pain relievers for an injury, filling
your prescription at a participating local pharmacy is optimal. Simply present your MedImpact Member ID card to
your pharmacist and pay your copayment as shown in the appropriate charts.
For medications you take regularly
For prescription medications you take regularly to treat ongoing conditions (maintenance medications such as these
used to treat high-blood pressure or diabetes), you may fill a 90-day supply for your convenience. See below for
how to get started with the MedImpact Direct Mail Program. You may also fill your 90-day supply at a participating
local pharmacy.
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For medications taken for complex conditions (specialty medications)
For specialty medications used to treat complex conditions, such as medications that treat cancer or multiple
sclerosis, MedImpact Direct Specialty can help. While MedImpact Direct Specialty isn’t a neighborhood pharmacy
you can walk into, we can have your specialty medications delivered to your home, office or location of your choice.
Visit [Link] to get started. You may also get your specialty medications at any in-network pharmacy
that carries it (i.e., you are not limited to only MedImpact Direct Specialty for specialty medications).
Please note: You must use 75% of your medication before requesting a refill (controlled substance refill threshold
is 80%).
Using an out-of-network pharmacy
Most pharmacy chains such as CVS, Walmart, Walgreen’s, and Giant, as well as independent pharmacies are in
network. However, if you use a pharmacy that’s not covered in the network, you must pay the entire cost of the
medication and then submit a claim for reimbursement. Claim forms are located online at [Link] and
can also be requested by calling MedImpact Healthcare Systems, Inc. Customer Care at 1-844-348-8508. Claims
must be submitted within 365 days of the prescription purchase date. You will be reimbursed for the amount the plan
would have paid if you had obtained your medication at a participating local pharmacy, minus the appropriate
copayment.
MedImpact Direct Mail Program, Birdi Pharmacy
Filling your prescriptions through the MedImpact Direct Mail program offers the most convenient way to get your
medications. The Program includes Birdi™ as your mail pharmacy for home delivery of maintenance medicine.
These are medications you take for conditions like high blood pressure and diabetes.
Birdi makes it easy to manage the medicine you take to help stay healthy. When you use Birdi, you can rely on:
• Up to a 90-day supply of your medications for two copayments
• No-cost standard shipping in weather-resistant packaging
• After hours service: Call Birdi at 1-855-873-8739 (TTY dial 711)
• Refill reminders to help you have the right amount of medicine on hand
How Do I Get Started with Birdi™?
Online: Sign in to the MedImpact website at [Link] to request a new prescription or transfer from a
retail pharmacy. Choose “Transfer/Request Prescriptions” at the top of “My Prescriptions -> Prescription List” page
and follow the instructions.
Mobile: Our mobile app gives you a secure, simple way to manage your prescription benefits and plan member
information. You’ll find easy-to-use tools that help you save time, get organized and stay on your path to better
health. Find a nearby pharmacy no matter where you are. Learn about your medication and get information you can
trust day or night. Do all this—and much more—at your convenience. To download our mobile app, visit the App
store or Google Play by searching “MedImpact” (after your benefits begin).
By Mail: Ask your doctor to provide you with a written prescription for your medications. Sign in to
[Link] and choose Documents -> Medication Order Form. Print and send the form with your
prescription(s) to:
Birdi
PO Box 8004
Novi, MI 48376-8004
By fax or electronic submission from your doctor: Have your doctor’s office fax or electronically send the
prescription for a 90-day supply, plus the appropriate number of refills (maximum one-year supply).
Fax to 1-888-783-1773.
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Important notes:
• Faxes must be sent from your doctor’s office
• Faxes from other locations, such as your home or workplace, cannot be accepted
• You must use 75% of your medication before you can request a refill through mail service (80% of your
medication for controlled substances)
MedImpact Direct Specialty
The MedImpact Direct Specialty® Program helps our members with complex conditions get their specialty medicine.
Doctors use these drugs to treat chronic conditions such as cancer or hepatitis C. These drugs usually need special
care, close follow-up, and support for the way you take the drug. Whether this medicine is new for you, or if you
have been taking it for a while, the dispensing pharmacy will help you get the most from your medicine.
Getting started
For specialty medications, you don’t need to do anything. Your dispensing pharmacy will call you to schedule
delivery. If you have questions, call MedImpact Direct Specialty at 1-877-391-1103 (TTY dial 711).
Personal Support for You
You will get personal support for your therapy. After-hours care from the nurse and/or pharmacies can help you
24/7/365. Call the phone number on your medicine label to talk to care teams. Care teams will schedule your therapy
and give you support to help you get the most from your medicine. They can answer questions about how to take
your medicine or help with managing side effects. They will help you with your benefit and research financial support
if those services are needed.
Convenient Dispensing and Delivery
The network pharmacy will ship your medicine to you or your doctor, depending on who is administering the drug.
If your doctor administers your medicine in the office, it will be shipped to your doctor. If you administer the medicine
yourself, it will be shipped to you at the address you provide, in private packaging that doesn’t indicate what is in
the box.
MedEmpower Fuel Diabetes Management Program
MedEmpower Fuel is a health benefit that combines advanced blood glucose testing technology with coaching to
support chronic health conditions like diabetes. It is available at no cost to you as part of your MedImpact Healthcare
Systems, Inc. prescription benefit plan.
What’s included at $0 cost to you:
• An integrated Glucometer
• As many strips as you need
• Lancing device, lancets, and carrying case
• Clinical coaching
• Anytime access to Certified Diabetes Educators and educational materials
• Mobile app
• Medication tracking integration
• And more
Look for more information about this program at [Link].
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Utilization Management Programs
To promote safety along with appropriate and cost-effective use of prescription medications, the plan includes
several utilization management programs.
Step therapy
Step therapy is a process for finding the best treatment while ensuring you are receiving the most appropriate
medication therapy and reducing prescription costs. Medications are grouped into two categories:
• First-line medications: These are the medications recommended for you to take first—usually generics, which
have been proven safe and effective. You pay the lowest copayment for these.
• Second-line medications: These are brand-name medications. They are recommended for you only if a first-line
medication does not work. You may pay more for brand-name medications.
These steps follow the most current and appropriate medication therapy recommendations. MedImpact Healthcare
Systems, Inc. will review your records for step therapy medications when you go to the pharmacy to fill a
prescription. If your prescription is for a step therapy medication, the pharmacy will search your prescription records
for use of a first-line alternative. If prior use of a first-line medication is not found, the second-line medication will not
be covered. You will need to obtain a new prescription from your doctor for one of the first-line alternatives, or have
your doctor request a prior authorization for coverage of the second-line medication. For more information on step
therapy, visit [Link] or call MedImpact Healthcare Customer Service at 1-844-348-8508.
Prior authorization (PA)
Prescriptions for certain medications require a Prior Authorization—also known as a coverage review— to ensure
the medication is cost-effective and clinically appropriate. This review uses formulary, clinical guidelines and other
criteria to determine if the plan will pay for certain medications. At the time you fill a prescription, the pharmacist is
informed of the Prior Authorization requirement through the pharmacy’s computer system and your doctor will need
to contact MedImpact Healthcare Systems, Inc.’s Prior Authorization department to provide justification for
MedImpact’s consideration of why you should be on the prescribed medication.
The following are examples that may require Prior Authorization for your prescription:
• Your doctor prescribes a medication not covered by the formulary
• The medication prescribed is subject to age limits
• The medication is only covered for certain conditions
If the Prior Authorization is denied, written notification is sent to both you and your provider. You have the right to
appeal the denial through the appeals process. The written notification of denial you receive provides instructions
for filing an appeal. For more information on Prior Authorization, visit [Link] or call MedImpact
Healthcare Systems, Inc. at 1-844-348-8508.
Quantity limits
For some medications, such as medications used to treat pain or sleep disorders, your plan covers a limited quantity
within a specific time period. These limits are based on FDA-approved prescribing information, approved medical
guidelines and/or the average utilization quantity for the drugs. Some medications with quantity limits have a Prior
Authorization available if a greater quantity is medically necessary.
Appeals
If a Prior Authorization is denied, you or your representative may appeal the decision by proceeding with the Appeal
procedure listed on the denial letter. If you require an urgent review, call MedImpact Healthcare Systems, Inc. at 1-
844-348-8508 for instructions. Please note that not all appeal requests are eligible for the urgent review process.
Urgent appeals will be decided within 72 hours. If you choose to fill this prescription without Prior Authorization
approval, you will be responsible for the full cost of the medication. You have a right to receive, upon written request
and at no charge, information used to review your request. Appeals must be submitted within 180 calendar days
after you receive the notice of a denial of a Prior Authorization. For more information regarding appeals, refer to the
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“Evidence of Coverage” document located on the DBM Health Benefits Prescription Drug Coverage page
([Link]
Vaccinations
Some vaccines are covered under the prescription benefit, such as those for the flu, COVID-19, pneumonia and
shingles. Members can use their MedImpact Healthcare Systems, Inc. ID card at any participating pharmacy.
Claims inquiry
If you believe your claim was incorrectly denied or you have questions about a processed claim, call MedImpact
Healthcare Systems, Inc. at 1-844-348-8508.
Vacation overrides
If you are going on vacation or out of the country for at a minimum of 30 days, we will provide an early refill approval
for up to a 90 day supply of medication, you must complete an Out of Country Early Refill Prescription Drug
Request Form. Once completed, fax it to the number listed on the form to receive the State’s approval. Your form
must include supporting documentation related to your trip (plane ticket confirmation, itinerary, letter, etc.) or it will
not be reviewed. If you have additional questions, please contact MedImpact Healthcare Systems, Inc. at 1-844-348-
8508 for assistance.
Privacy
Your State of Maryland Benefit Plan meets the provisions of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA) to assure your health information is properly protected. MedImpact Healthcare Systems, Inc. is
committed to meeting both the HIPAA and State of Maryland guidelines related to protecting your privacy.
All services listed are available 24 hours a day, 7 days a week.
Customer Service: 1-844-348-8508 (TTY dial 711)
MedImpact Direct Mail: 1-855-873-8739
MedImpact Direct Specialty: 1-877-391-1103
Online Resources
[Link]