Medicare Prescription Coverage

UPMC for Life Part D Prescription Drug Coverage

Make sure your prescription drugs are covered. UPMC for Life covers thousands of brand-name and generic medications. These drugs are reviewed and approved by UPMC physicians, community pharmacists, and Medicare.

Jump to a section:

• Prescription Drug Formularies
• Drug tiers
• Top 200 drug list
• $0 copay for Tier 1 and 2 medications at preferred pharmacies
• Insulin medications
• Preferred pharmacies
• Prior authorization requirements
• Step therapy
• Quantity limits
• Part B drugs and supplies
• Help with medication costs
• Medication Therapy Management (MTM) program

Prescription Drug Formularies

UPMC for Life has two Part D prescription drug formularies. A formulary is a list of covered drugs for your plan. The name of the formulary and the plans that use it are important for you to know when reviewing your prescription drug coverage. Drug coverage is different between these formularies, so it's good to make sure you review the formulary for your plan in detail.

Each formulary has five levels of drug benefits. These levels are referred to as drug tiers. Learn about our drug tiers below, along with benefits that can help you save money on covered prescription drugs.

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UPMC for Life drug tiers

1. Preferred Generic
2. Generic
3. Preferred Brand
4. Non-Preferred Drug
5. Specialty

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Top 200 drug list

Our top 200 drug list includes the most commonly used prescription drugs for members in our UPMC for Life plans along with their drug tiers.

UPMC for Life 2024 top 200 drug list

This is not a complete list of the drugs we cover. See your plan formulary for a complete list.

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$0 copay for Tier 1 AND 2 medications at preferred pharmacies

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HMO Rx members have additional donut hole coverage for generic medications on Tier 1 and 2

Members on the UPMC for Life HMO Rx (HMO) plan have additional coverage through the Medicare Part D coverage gap, “donut hole.” Members in this plan pay the same copays for generic medications on Tiers 1 and 2 in the Part D initial coverage and donut hole stages. That means members will not pay more in the donut hole.

Learn more about Tier 1 and 2 coverage through the donut hole.

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Insulin medications

UPMC for Life members have coverage through the “donut hole” for covered insulin!

Your copay for covered insulin is the same during the initial coverage and coverage gap "donut hole" stages, which may save you hundreds! This applies to covered insulins filled at standard, preferred, or mail-order pharmacies in 2024.

• $35 copay for a 30-day supply filled at retail pharmacies
• $87.50 copay for a 100-day supply filled at a preferred mail-order pharmacy
• $96.25 copay for 100-day supply filled at a preferred retail pharmacy
• $105 copay for a 100-day supply filled at standard pharmacies

Learn more about cost savings for members with diabetes.

Covered insulins have a maximum $35 copay for each one-month supply. This means you will not pay more than $35 for a 30-day supply or more than $105 for a 100-day supply during the initial coverage stage or donut hole. Once you reach the catastrophic stage, you will no longer pay for your prescriptions. Your Medicare Advantage plan will be responsible for paying your share of the cost for your prescriptions. See your plan Evidence of Coverage for more information.

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Take advantage of preferred pharmacies

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Prior authorization requirements

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Step therapy requirements

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Quantity Limits

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Part B Drugs and Supplies

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Get help with medication costs

If you have limited income, you may qualify for Extra Help to pay for your prescription drugs. Many people are eligible for these savings and don't even know it. See the Low-Income Subsidy Premium Summary Table below to get details about low income subsidies in your area.

2024 Low Income Subsidy Premium Summary Table, Last updated 10/1/2023

Language assistance

Apply for Extra Help with your medications at socialsecurity.gov

How do I ask about my LIS status or level?

To find out about your LIS status or level, call:

• 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-800-633-4227.
• Social Security at 1-877-486-2048 Monday through Friday from 8 a.m. to 7 p.m. TTY users should call 1-877-486-2048.
• Your state Medical Assistance (Medicaid) office.
• In Pennsylvania the Medicaid program is managed by the Department of Human Services (DHS). In Ohio the Medicaid program is managed by the Department of Medicaid.
• Medicare may not have the correct income information to give UPMC for Life at the time a person is applying for help. The Best Available Evidence policy helps plans review costs for those members.

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Medication Therapy Management (MTM) program

UPMC Health Plan has developed a unique medication therapy management program for members who take many medications and meet certain criteria.

Use the links below to learn more:

• About the program
• Who is eligible for UPMC for Life's medication therapy management program?
• How can I safely dispose of my medications

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