ALERT: The UPMC Health Plan web portals are experiencing intermittent slowness and connectivity issues at this time. We apologize for the inconvenience and thank you for your patience.

UPMC for Life Prescription Drug Transition Process

Does UPMC for Life meet Medicare requirements for pharmacy access?

Yes, the number of pharmacies in your area that are in the UPMC for Life network equals or exceeds CMS requirements for pharmacy access.


UPMC for Life Prescription Drug Transition Process


What should I do before I can talk to my doctor about changing my prescription drugs or requesting an exception to the UPMC for Life formulary?

As a new member to our plan you may be taking drugs that are not on our formulary, or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before we will pay for your prescription. You should talk to your doctor to decide if you should switch to another drug that we cover or make a coverage request. During the first 90 days that you are a member of our plan, we may cover a limited amount of your current drug therapy in certain cases while you talk to your doctor to determine the right course of action for you.

For Non-Long-Term Care Residents:

For any drug that you are currently taking that is not on our formulary, or that requires additional authorization, we will cover multiple fills to provide at least 30 days of medication (unless you have a prescription written for fewer days) when you fill the prescription at a network pharmacy. If you are given this temporary supply, please speak to your doctor before you use the entire supply so you and your doctor can select a formulary alternative or make a coverage request. We will not pay for this drug beyond your first 30-day supply unless you have been approved for a coverage request.

For Long-Term Care Residents:

If you are a resident of a long-term care facility, we will cover a temporary transition supply up to 93 days. We will cover additional refills if needed for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or is subject to additional authorization, but you are past the first 90 days of membership in our plan, we will cover up to a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a coverage request or work with your physician to select a formulary alternative.

For Members Moving from Home to a Long-Term Care Facility or from a Long-Term Care Facility to Home:

If your level of care changes (e.g., entering a long term-care facility or going home after a stay in a long-term care facility), UPMC for Life again provides transitional supplies of non-formulary or otherwise restricted medications. For the first month after entering a long-term care facility or for the first month after being discharged from a long-term care facility, you can get up to a one-month supply of your current medications to allow time for you and your physician to switch to a formulary alternative or request an exception.

How do I inquire about my LIS status or level?

If you would like to inquire about your LIS status or level, call:

  • The Social Security Administration at www.socialsecurity.gov/prescriptionhelp. You can also call 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778
  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, seven days a week.
  • Your State Medical Assistance (Medicaid) Office.

How does UPMC for Life manage drug utilization?

One of UPMC for Life's primary goals in designing drug formularies and utilization programs is to promote safe and effective use of medications for our members. Using the data that we have compiled over the years, we have built safeguards into our pharmacy system designed to minimize the chances of harmful drug interactions in our members.

UPMC for Life has identified major drug interactions and sends an electronic warning to a retail pharmacist if the pharmacist tries to fill a prescription for a drug that interacts adversely with another medication the member is currently taking. This service has been available to our members for some time, and it is constantly reviewed as new drugs come to market, or as new and potentially harmful drug combinations are discovered.

Drug utilization is also reviewed after prescriptions for medications have been filled. Our internal clinical pharmacy team reviews, reports, and identifies members who are potentially at risk for adverse drug events. The team then contacts the members' doctors to discuss potential problems uncovered during the review.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

The UPMC for Life Medicare Advantage HMO and PPO plans are available to persons entitled to Medicare Part A and enrolled in Part B. You must continue to pay your Medicare Part B premium, reside in the service area, and not have end-stage renal disease (ESRD).

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 1-800-361-2629). We are available October 1 through February 14, seven days a week from 8 a.m. to 8 p.m. From February 15 through September 30, we are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m.

UPMC for Life has a contract with Medicare to provide HMO and PPO plans. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., and UPMC Health Benefits Inc.

The Silver&Fit program is a product of American Specialty Health Fitness, Inc., (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). All programs and services are not available in all areas. Silver&Fit® is a federally registered trademark of ASH and used with permission herein.

*Our hours of operation change twice a year.

You can call us:

October 1 through February 14:
seven days a week from 8 a.m. to 8 p.m.

February 15 through September 30:
Monday through Friday: 8 a.m. to 8 p.m.
Saturday: 8 a.m. to 3 p.m.

Y0069_18_1122 Approved

Last Updated: 10/01/2017
Apple Store Google Play