Prescription Drug Coverage
According to this prescription drug program, you may receive coverage for prescription drugs in the amounts specified in your rider when you fill your prescription at a UPMC Health Plan participating pharmacy. To be eligible for benefits, you must purchase your outpatient prescription drugs from a participating pharmacy or through the mail-order program.
The Your Choice formulary is a five-tier formulary consisting of a Preferred Generic Medication tier, a Preferred Brand Medication tier, a Non-Preferred Medication tier, a Specialty Medication tier, and a $0 Preventive Medication tier. Brand drugs on the Preferred Brand Medication tier are available to members at a lower cost-share than non-preferred medications. Formulary high-cost medications such as biologicals and infusions are covered on the Specialty tier, which may have a stricter days'-supply than the other tiers. The $0 Preventive Medication tier includes some preventive medications covered at no cost share when certain criteria is met in accordance with the Patient Protection and Affordable Care Act of 2010 (PPACA). Some medications may be subject to utilization management criteria, including, but not limited to, prior authorization rules, quantity limits, or step therapy. Selected medications are not covered by this formulary.
Some medications may require that your provider consult with UPMC Health Plan's Pharmacy Services Department before they prescribe the medication for you. Pharmacy Services must authorize coverage of those medications before you fill the prescription at the pharmacy. Please see your formulary book for a listing of medications that require prior authorization.
Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred course of treatment may be generic medications, preferred brand medications or drugs that are considered as standard first-line treatment. Please see your formulary book for a listing of medications that require step therapy.
UPMC Health Plan has established quantity limits on certain medications to comply with the guidelines established by the Food and Drug Administration (FDA) and to encourage appropriate prescribing and use of these medications. Also, the FDA has approved some medications to be taken once daily in a larger dose instead of several times a day in a smaller dose. For these medications, your benefit plan covers only the larger dose per day.
Your pharmacy benefit plan may cover additional medications and supplies and may exclude medications that are otherwise listed on your formulary. Your benefit plan may also include specific cost-sharing provisions for certain types of medications or may offer special deductions in cost-sharing for participating in certain health management programs. Please read this section carefully to determine additional coverage information specific to your benefit plan.
- Oral contraceptives.
- Weight-loss drugs. These medications require prior authorization.
- The FDA-approved oral erectile dysfunction medications that are used on an as-needed basis (such as sildenafil, tadalafil, and vardenafil) and are subject to a utilization management quantity limit. Tadalafil (5 mg) and sildenafil (all strengths) tablets have a quantity limit of 6 tablets per 30 days. Tadalafil (10 mg, 20 mg) and vardenafil tablets have a quantity limit of four tablets per 30 days. Tadalafil 2.5 mg, Muse, Caverject, and Edex are excluded from coverage.
- Some preventive medications at no cost share when you meet certain criteria in accordance with the Patient Protection and Affordable Care Act of 2010 (PPACA).
- Special cost-sharing provisions for diabetic supplies:
- Each individual item in a group of diabetic 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 copayment associated with the non-preferred brand name medication.
Please reference your plan's Prescription Drug Rider, Preventive Drug List, and the Your Choice formulary for further information.
Pharmacy Formulary (2020)
Prescription Drug Price Tool