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.

Select One HMO Deductible Rx (HMO) HMO Premier Rx (HMO) HMO Rx (HMO) HMO Rx Choice (HMO) HMO Rx Enhanced (HMO) PPO High Deductible Rx (PPO) PPO Premier Rx (PPO) PPO Rx Choice (PPO) PPO Rx Enhanced (PPO) HMO PPO Employer Group

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.

UPMC for Life drug tiers

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

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

Starting Jan. 1, 2024, our $0 drug list will also include Tier 2 medications. These prescriptions have a $0 copay when filled at preferred pharmacies during the initial coverage stage. That means members on the Advantage Rx formulary also have a $0 copay for brand-name diabetes medications on Tier 2. See your plan formulary for a complete list of covered Tier 1 and 2 medications.

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.

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.

Take advantage of preferred pharmacies

Members can fill prescriptions at any in-network pharmacy of their choice and can have low copays when filling at one of our preferred retail or mail-order pharmacies. Some preferred retail pharmacy locations include Giant Eagle, Rite Aid, Sam’s Club, Walgreens, Walmart, and Weis. Search for a preferred pharmacy near you.

With Express Scripts, our preferred mail-order pharmacy, you can have your prescriptions delivered right to your door! Simply ask your doctor to send your prescription to Express Scripts or call 1-877-787-6279 (TTY: 1-800-899-2114) 24 hours a day, 7 days a week. Your medications should be delivered within 15 business days. If your medications do not arrive within this time frame, call the phone number above.

Make sure to use your UPMC for Life member ID card when filling medications to be sure you get the lowest copays available.