Pharmacy Services from MedImpact

MedImpact Healthcare Systems  manages pharmacy benefits for some Prominence Administrative Services and Prominence Health Plan members.

Employers managed by MedImpact include Boomtown Casino.


MedImpact Pharmacy Processing Information

BIN = 003585
Group = UPH

2020 Self-funded Pharmacy Formulary (PDF) >
2020 Self-funded Pharmacy Formulary (SPA) (PDF) >

Specialty Pharmacy Care

A specialty pharmacy program supports patients with complex health conditions who need injectable medications, or medications with strict compliance requirements or special storage needs.

Pharmacy by Mail Program

The pharmacy mail order program is administered by MedImpact Direct. Members can obtain a 90-day supply for ongoing medication(s) and you can save money and time by having prescriptions for maintenance medication(s) delivered right to your home.

Get more information about MedImpact Direct Pharmacy by Mail >

Pharmacy Forms

Drug Exception Process

How do I request an exception to the Plan Formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Prominence Administrative Services will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception.

When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.  For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.