How many pharmacies are in the UPMC for Life Network?
Ohio — 2,315
Pennsylvania — 2,911
West Virginia — 499
Does the UPMC for Life PDP meets access requirements?
Yes, the number of pharmacies in your area that are in the UPMC for Life network equals or exceeds CMS requirements for pharmacy access.
As a new member to 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 we will pay for your prescription. You should talk to your doctor to decide if you should switch to another drug that we cover or request a formulary exception. During the first 90 days that you are a member of our plan, we may cover a limited amount of your current non-formulary drug therapy in certain cases while you talk to your doctor to determine the right course of action for you.
For any drug that you are currently taking that is not on our formulary, or that requires additional authorization, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you fill the prescription at a network pharmacy. If you are given this temporary supply, please speak to your doctor before you use the entire supply so you and your doctor can select a formulary alternative or request an exception. We will not pay for this drug beyond your first 30-day supply unless you have been approved for a formulary exception.
If you are a resident of a long-term care facility, we will cover a temporary transition supply up to 30 days. We will cover additional refills if needed for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or is subject to additional authorization, but you are past the first 90 days of membership in our plan, we will cover up to a 30-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception or work with your physician to select a formulary alternative.
For Members Moving from Home to a Long-Term Care Facility or from a Long-Term Care Facility to Home:
If your level of care changes (e.g., entering a long term-care facility or going home after a stay in a long-term care facility), UPMC for Life again provides transitional supplies of non-formulary or otherwise restricted medications. For the first month after entering a long-term care facility or for the first month after being discharged from a long-term care facility, you can get up to a one-month supply of your current medications to allow time for you and your physician to switch to a formulary alternative or request an exception.
How does UPMC for Life help members who take many medications?
UPMC for Life members who have multiple chronic diseases, take many medications regularly, and have an expensive drug therapy regimen may need some help managing their medications. UPMC Health Plan has developed a unique medication therapy management program for them. The program is administered by a team of UPMC Health Plan health care professionals, including clinical pharmacists, registered nurses, caseworkers, clinical psychologists, and support staff, under the guidance of the Medicare Medical Director.
The Centers for Medicare & Medicaid Services (CMS) requires companies that offer Part D benefits to also offer a medication therapy management program. Members who meet the three criteria listed above must be given the option to participate in this program.
The program includes:
- A complete review of the member’s medications, with a focus on safety and on educating members about their diseases and their medications
- Assistance in finding transportation services for doctor appointments, if needed
- Referral to assistance agencies, such as the department of aging and community resources, if needed
- Education and encouragement to comply with medication regimens
- Assessment of the member’s support network
- Education on coping mechanisms, especially with regard to caregivers
These interventions that help members better use their medical and community resources are not new to UPMC Health Plan. They were in effect at the Health Plan long before we contracted with CMS to offer Part D benefits.
What are the criteria for a member to be eligible for the medication management program?
A UPMC for Life member must meet the following criteria to be eligible for UPMC for Life’s medication therapy management program.
- The UPMC for Life member must have 4 of the following 9 chronic diseases: AIDS/HIV, dyslipidemia, Alzheimer’s/ dementia, multiple sclerosis, osteoporosis, chronic pain, diabetes, lung disease, or chronic heart disease.
- The UPMC for Life member must have filled 9 chronic/maintenance Part D covered drugs in a three-month period.
- The UPMC for Life member is likely to incur annual costs that meet or exceed $4,000 for all covered Part D drugs. (UPMC estimates members who will have an annual drug cost of at least $4,000 by selecting members whose drug costs equal or exceed $1,000 in a three-month period)
Please note: This program is not considered a benefit.
For more information regarding UPMC for Life’s medication therapy management program, please call our Member Services Department at 1-877-539-3080 between 8 a.m. and 8 p.m., seven days a week (TTY: 1-800-361-2629).
How does UPMC for Life manage drug utilization?
One of UPMC for Life's primary goals in designing drug formularies and utilization programs is to promote safe and effective use of medications for our members. Using the data that we have compiled over the years, we have built safeguards into our pharmacy system designed to minimize the chances of harmful drug interactions in our members.
UPMC for Life has identified major drug interactions and sends an electronic warning to a retail pharmacist if the pharmacist tries to fill a prescription for a drug that interacts adversely with another medication the member is currently taking. This service has been available to our members for some time, and it is constantly reviewed as new drugs come to market, or as new, potentially harmful drug combinations are discovered.
Drug utilization is also reviewed after prescriptions for medications have been filled. Our internal clinical pharmacy team reviews, reports, and identifies members who are potentially at risk for adverse drug events. The team then contacts the members' doctors to discuss potential problems uncovered during the review.
How do I inquire about my LIS status or level?
If you would like to inquire about your LIS status or level, call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week.
- Social Security at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778, between 7 a.m. and 7 p.m., Monday through Friday.
- Your State Medicare Assistance (Medicaid) Office. In Pennsylvania, the Medicaid program is managed by the Department of Public Welfare (DPW).
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