2012 Part D Prescription Drug Coverage
Our Special Needs products offer Part D prescription drug coverage as part of our plans. Use the documents and links below to gather important information about the types of prescription drug coverage that UPMC for You Advantage, UPMC for Life Specialty Plan, and UPMC for Life Options offers, what drugs are covered under our prescription drug formulary, and what pharmaciesparticipate in our network.
UPMC for Life Specialty Plan members utilize the UPMC for Life Formulary, Pharmacy, and Prescription Drug Forms.
Prescription Drug Formulary Information
- 60-day Formulary Change Information* — coming soon
- UPMC for Life Prior Authorization Information for Prescription Drugs*
- Step Therapy Requirements Document
- Quantity Limits — coming soon
Reimbursement for a Pharmacy Claim
Prescription Drug Authorizations, Exceptions, Redeterminations, and Grievances (to UPMC for Life Formulary)
- What should I do before talking to my doctor about changing my prescription drugs or requesting an exception to the UPMC for Life formulary?
- Prescription Drug Coverage Determination Form/Exception Request Form*
- Prescription Drug Coverage Redetermination Form
To ask for an appeal about a Part D drug and/or Part C medical care or service, a signed, written appeal request must be faxed to UPMC for Life Specialty Plan or sent to the address listed below.
FAX: 412-454-7920
WRITE: UPMC Health Plan
Attn: Appeals and Grievances
P.O. Box 2939
Pittsburgh, PA 15230-2939
You may also ask for an appeal by calling our Member Services Department seven days a week from 8 a.m. to 8 p.m. at 1-800-606-8648.* TTY users should call 1-866-407-8762.
Medication Transition Process
New members in our Plan may be taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.
- Members currently residing in a non long-term care facility — transition process
- Members currently residing in a long-term care facility — transition process
- Members moving from home to a long-term care facility or from a long-term care facility to home — transition process
How to obtain an aggregate number of grievances and appeals:
Please call our Member Services Department seven days a week from 8 a.m. to 8 p.m. at 1-800-606-8648 if you need more information about the number of appeals and grievances filed by our members. TTY users should call 1-866-407-8762. From March 2 through November 14 you may receive a messaging service on weekends and holidays. Please leave a message and your call will be returned the next business day.
Out-of-Network Coverage*Participating Providers and Pharmacies
- UPMC for You Advantage and UPMC for Life Specialty Plan UPMC for Life Options — coming soon
Members must use network pharmacies to access your prescription drugs, except in non-routine circumstances. Quantity limitations and restrictions may apply.
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost when you fill your prescription.
Information for People Who Need Extra Help to Pay for Their Prescription Drugs
- Sign-up for extra help for paying for your prescription drugs
- How do I inquire about my LIS status or Level?
- View Low Income Subsidy Website Premium Summary Table for Pennsylvania
- Link to CMS Website – Best Available Evidence (BAE)
- Medicare Prescription Drug Plan Finder
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week.
- Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m. Monday through Friday. TTY users shoudl call 1-800-325-0778.
UPMC for Life Medication Management Program
For Important Plan Information, please click here.
To see our Frequently Asked Questions page for more information and common questions asked by Medicare Specialty Program beneficiaries, please click here.
If you have any questions or would like to receive this information by mail, please call us toll-free at 1-866-405-8762 from 8 a.m. to 8 p.m.,* seven days a week or click on one of the links below. TTY/TDD users should call 1-866-407-8762.