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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

Your Choice: The Your Choice formulary is a four-tier formulary consisting of a Generic tier, a Preferred brand tier, a Non-Preferred brand tier, and a Specialty drug tier. Brand drugs on the Preferred tier are available to members at a lower cost-share than non-preferred brands. Formulary high-cost medications such as biologicals and infusions are covered in the Specialty tier, which may have a stricter days'-supply than the other tiers. 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 with this formulary.

Medications Requiring Prior Authorization

Some medications may require that your physician consult with UPMC Health Plan's Pharmacy Services Department before he or she prescribes the medication for you. Pharmacy Services must authorize coverage of those medications before you fill the prescription at the pharmacy. Please see your pharmacy brochure for a listing of medications that require prior authorization.

Quantity Limits

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.

Additional Coverage Information

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.

  • Your pharmacy benefit plan includes coverage for oral contraceptives.
  • Your pharmacy benefit plan includes coverage for the FDA-approved oral erectile dysfunction medications that are used on an as-needed basis (Viagra, Cialis, and Levitra) subject to a utilization management quantity limit of four tablets per 30 days. However, Cialis 2.5 mg, Muse, and Caverject are excluded from coverage.
  • Your pharmacy benefit includes PPI step therapy requirement.
  • Your pharmacy benefit plan includes 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.
  • Your pharmacy benefit plan includes coverage for special cost-sharing provisions for choosing brand-name over generic drugs:
    • According to your formulary, generic drugs will be substituted for all brand-name drugs that have a generic version available.
    • If the brand-name drug is dispensed instead of the generic equivalent, you must pay the copayment associated with the brand-name drug as well as the price difference between the brand-name drug and the generic drug.
    • If your prescribing physician demonstrates to UPMC Health Plan that a brand name drug is medically necessary, you will pay only the copayment associated with the non-preferred brand name drug.

Please reference your plan's Prescription Drug Rider, Preventive Drug List, and the Your Choice formulary for further information.

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Attention

It is important to know that when you enroll in this plan, services are provided through UPMC Health Plan's participating providers as described in UPMC Health Plan's federal brochure — but the continued participation of any one doctor, hospital, or other provider cannot be guaranteed.

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