prescription drug coverage with UPMC

Prescription Drug Coverage

Your pharmacy benefit plan includes coverage for:

    • UPMC Health Plan offers the full range of contraceptive methods. 

    • The only products that are not readily available are multi-source brand contraceptive drugs.

    • For a $0 copayment on multi-source brand contraceptives, your provider must submit a Cost Sharing Exception request form. It is included with the Preventive Services Resource Guide or downloadable from the Pharmacy Prior Authorization section of our website. 

    • Your provider can also directly submit an electronic request through UPMC’s PromptPA Portal (https://www.upmchealthplan.com/providers/medical/resources/forms/pharmacy-pa.aspx).

    • To be approved for a cost-sharing exception, your provider must attest that the prescribed medication is medically necessary and explain why it is a necessary form of contraception.

    • Questions? Contact the UPMC MyHealth 24/7 Nurse Line at 1-866-918-1591 (TTY: 711) for nonemergency health questions or Member Services at 1-877-648-9641 (TTY: 711). 
    If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov
  • Weight-loss drugs. These medications require prior authorization.
  • Drugs for the treatment of infertility including IVF, Artificial Insemination and cryopreservation.
  • Your pharmacy benefit plan includes coverage for FDA-approved sexual or erectile dysfunction medications with quantity limit requirements. Tadalafil 2.5 mg, Muse, Caverject, and Edex are excluded from coverage. The female drugs include: Addyi, Imvexxy, Intrarosa, Osphena, and Vylessi.
  • Special cost-sharing provisions for diabetes supplies:
    • Each item in a group of diabetes supplies—including, but not limited to, insulin, injection aids, needles, and syringes—is subject to a separate copayment.
  • Special cost-sharing provisions when you choose brand-name medications instead of generic medications:
    • According to your formulary, generic medications will be substituted for all brand-name medications that have a generic version available.
    • If the brand-name medication is dispensed instead of the generic equivalent, you must pay the copayment associated with the brand-name medication as well as the price difference between the brand-name medication and the generic medication.
    • If your prescribing physician demonstrates to UPMC Health Plan that a brand-name medication is medically necessary, you will pay only the nonpreferred medication copayment.