Complete Care Member Guide

14 Covered prescription drugs UPMC for Life Complete Care covered drug list Taking your prescriptions as directed by your doctor is important. UPMC for Life Complete Care wants to make it as easy and affordable as possible for you to get the medications you need and to follow your doctor’s plan of care. That’s why UPMC for Life Complete Care works with community doctors and pharmacists to maintain a list of drugs that are covered by our plan. This is also called a formulary. Each drug on our formulary is selected by the plan based on the drug’s safety, effectiveness, and cost. We also review and update the formulary regularly during the year. For the most current list of drugs our plan covers, visit upmchealthplan.com/snp. Restrictions on coverage for some drugs Special rules limit how and when the plan covers certain prescription drugs. A team of doctors and pharmacists developed these rules to help our members access drugs in the most effective way. These rules are approved by the Centers for Medicare & Medicaid Services (CMS). They also help control drug costs, which keeps your coverage more affordable. If there is a restriction for a drug that you are taking, such as a quantity limit, step therapy, or prior authorization, you or your providers must take additional steps for us to cover the drug. If a drug you are taking is not on our formulary, you can ask us to decide whether to add it. This decision takes the form of a coverage determination, redetermination, or appeal for a Part D prescription drug. You can fill out a request form on our website at upmchealthplan.com/snp. Click on the Additional Documents and Forms link at the top of the page. You can also call your Health Care Concierge team to receive a copy of the request form in the mail. Where and how to get your prescriptions To find participating pharmacies near you, visit upmchealthplan.com/find or call your Health Care Concierge team. Mail order UPMC for Life Complete Care contracts with Express Scripts Inc. to provide you with convenient home delivery of maintenance medications. These are drugs you take on a regular, long- term basis. (For example, you generally would not use Express Scripts for antibiotic medications.) To sign up, call 1-877-787-6279 (TTY: 1-800-899-2114). Your medications should be delivered within 15 business days. If your medications do not arrive within this time frame, call the phone number above.