learn about medicare prescription coverage (2024)

UPMC for Life Part D Prescription Drug Coverage

Make sure your prescription drugs are covered. UPMC for Life covers thousands of brand-name and generic medications. These drugs are reviewed and approved by UPMC physicians, community pharmacists, and Medicare.

Jump to a section:

• Prescription Drug Formularies
• Drug tiers
• Top 200 drug list
• $0 copay for Tier 1 and 2 medications at preferred pharmacies
• Insulin medications
• Preferred pharmacies
• Prior authorization requirements
• Step therapy
• Quantity limits
• Part B drugs and supplies
• Help with medication costs
• Medication Therapy Management (MTM) program

Prescription Drug Formularies

UPMC for Life has two Part D prescription drug formularies. A formulary is a list of covered drugs for your plan. The name of the formulary and the plans that use it are important for you to know when reviewing your prescription drug coverage. Drug coverage is different between these formularies, so it's good to make sure you review the formulary for your plan in detail.

Here are two easy ways to make sure your medications are covered:

• Search covered drugs (search our drug listby the name of the drug you are taking).
• Download a formulary (download the formulary for your plan using the drop down above).

Each formulary has five levels of drug benefits. These levels are referred to as drug tiers. Learn about our drug tiers below, along with benefits that can help you save money on covered prescription drugs.

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UPMC for Life drug tiers

1. Preferred Generic
2. Generic
3. Preferred Brand
4. Non-Preferred Drug
5. Specialty

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Top 200 drug list

This is not a complete list of the drugs we cover. See your plan formulary for a complete list.

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$0 copay for Tier 1 AND 2 medications at preferred pharmacies

Starting Jan. 1, 2024, our $0 drug list will also include Tier 2 medications. These prescriptions have a $0 copay when filled at preferred pharmacies during the initial coverage stage. That means members on the Advantage Rx formulary also have a $0 copay for brand-name diabetes medications on Tier 2. See your plan formulary for a complete list of covered Tier 1 and 2 medications.

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HMO Rx members have additional donut hole coverage for generic medications on Tier 1 and 2

Members on the UPMC for Life HMO Rx (HMO) plan have additional coverage through the Medicare Part D coverage gap, “donut hole.” Members in this plan pay the same copays for generic medications on Tiers 1 and 2 in the Part D initial coverage and donut hole stages. That means members will not pay more in the donut hole.

Learn more about Tier 1 and 2 coverage through the donut hole.

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Insulin medications

• $35 copay for a 30-day supply filled at retail pharmacies
• $87.50 copay for a 100-day supply filled at a preferred mail-order pharmacy
• $96.25 copay for 100-day supply filled at a preferred retail pharmacy
• $105 copay for a 100-day supply filled at standard pharmacies

Learn more about cost savings for members with diabetes.

Covered insulins have a maximum $35 copay for each one-month supply. This means you will not pay more than $35 for a 30-day supply or more than $105 for a 100-day supply during the initial coverage stage or donut hole. Once you reach the catastrophic stage, you will no longer pay for your prescriptions. Your Medicare Advantage plan will be responsible for paying your share of the cost for your prescriptions. See your plan Evidence of Coverage for more information.

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Take advantage of preferred pharmacies

Members can fill prescriptions at any in-network pharmacy of their choice and can have low copays when filling at one of our preferred retail or mail-order pharmacies. Some preferred retail pharmacy locations include Giant, Giant Eagle, Rite Aid, Sam’s Club, Walgreens, Walmart, and Weis. Search for a preferred pharmacy near you.

With Express Scripts, our preferred mail-order pharmacy, you can have your prescriptions delivered right to your door! Simply ask your doctor to send your prescription to Express Scripts or call 1-877-787-6279 (TTY: 1-800-899-2114) 24 hours a day, 7 days a week. Your medications should be delivered within 15 business days. If your medications do not arrive within this time frame, call the phone number above.

Make sure to use your UPMC for Life member ID card when filling medications to be sure you get the lowest copays available.

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Prior authorization requirements

Some of the drugs that UPMC for Life covers may require you and your doctor to get prior approval. Select your plan to see a list of which drugs require prior authorization.

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Step therapy requirements

In some cases you may need to first try certain drugs to treat a medical problem before we will cover another drug. Select your plan below to see which drugs require step therapy.

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Quantity Limits

For certain prescription drugs, our plan limits the amount of the drug that we will cover. Prescription drugs with quantity limits are listed in your plan’s comprehensive formulary (list of covered drugs). To see if any of your prescription drugs have a quantity limit, select your plan’s comprehensive formulary above and check for "QL" next to the drug name under Requirements/Limits.

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Part B Drugs and Supplies

The document below contains a list of select Part B drugs that UPMC for Life covers.
Covered Select Part B Drugs and Supplies, Last updated 12/22/2020

The document below contains a list of drugs that require Part B Step Therapy.
2024 Drugs and Products Requiring Part B Step Therapy or Prior Authorization, Last updated 6/28/2024

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Get help with medication costs

Apply for Extra Help with your medications at socialsecurity.gov

How do I ask about my LIS status or level?

To find out about your LIS status or level, call:

• 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-800-633-4227.
• Social Security at 1-877-486-2048 Monday through Friday from 8 a.m. to 7 p.m. TTY users should call 1-877-486-2048.
• Your state Medical Assistance (Medicaid) office.
• In Pennsylvania the Medicaid program is managed by the Department of Human Services (DHS). In Ohio the Medicaid program is managed by the Department of Medicaid.
• Medicare may not have the correct income information to give UPMC for Life at the time a person is applying for help. The Best Available Evidence policyhelps plans review costs for those members.

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Medication Therapy Management (MTM) program

• About the program
• Who is eligible for UPMC for Life's medication therapy management program?
• How can I safely dispose of my medications

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