Prescription Drug Coverage
According to this prescription drug program, you may receive coverage for prescription drugs in the amounts specified in your FEHB Brochure when you fill your prescription at a UPMC Health Plan participating pharmacy.
The Your Choice formulary consists of a Preferred Generic Medications tier, a Preferred Brand Medications and Generic Medications tier, a Nonpreferred Brand and Generic Medication tier, and a Specialty Medication (Brand and Generic) tier. Drugs on the Preferred Brand and Generic Medications tier are available to you at a lower cost-share than Nonpreferred Medications. High-cost medications such as biologicals and infusions are covered on the Specialty tier and may have a stricter days' supply than medicines on the other tiers. Your benefit also covers Preventive Medications with 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.
If a drug requires Prior Authorization, the UPMC Health Plan Pharmacy Services Department must authorize the use of this drug before it will be covered. Drugs that require Prior Authorization are often:
- Newer drugs for which UPMC Health Plan wants to track usage.
- Drugs not used as a standard first option in treating a medical condition.
- Drugs with potential side effects that UPMC Health Plan wants to monitor for patient safety.
- Drugs categorized as specialty medications.
Please see your 2024 formulary book for a list of medications that require prior authorization.
Pharmacy Prior Authorization Form
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 or drugs that are considered as the standard first-line treatment. Please see your formulary book for a list of medications that require step therapy.
Quantity Limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and manufacturer’s instructions. Quantity Limits promote appropriate use of the drug, prevent waste, and help control costs. Please see your formulary book for a list of medications that have a quantity limit.
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.
- 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) tablets have a quantity limit of 30 tablets per 30 days. Sildenafil tablets, tadalafil (10 mg, 20 mg) tablets and vardenafil tablets have a quantity limit of eight tablets per 30 days. Tadalafil 2.5 mg, Muse, Caverject, and Edex are excluded from coverage.
- Some preventive medications are covered 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 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 copayment associated with the nonpreferred brand-name medication.