UPMC for Life Complete Care 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.
All UPMC for Life Complete Care members have a $0 copay for covered Part D prescription drugs filled at a participating pharmacy. 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
- Prescription drug formulary
- 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.
Here are two easy ways to make sure your medications are covered:
- Search covered drugs (search our drug list by the name of the drug you are taking).
- Download a formulary (download the formulary for your plan using the drop down above).
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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Prescription drug formulary
The link below will allow you to see the UPMC for Life Complete Care (HMO SNP) prescription drug formulary. A formulary is a list of prescription drugs covered by your plan.
Two easy ways to make sure your medications are covered:
- Download the formulary using the link above.
- Search covered drugs (search our drug list by the name of the drug you are taking).
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UPMC for Life drug tiers
- Preferred Generic
- Generic
- Preferred Brand
- Non-Preferred Drug
- 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 Complete Care plans along with their drug tiers.
UPMC for Life 2024 top 200 drug list 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
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.
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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
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, 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.
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Prior authorization requirements
Some of the drugs that UPMC for Life covers may require you and your doctor to get prior approval. Select your plan to see a list of which drugs require prior authorization.
Some of the drugs that UPMC for Life covers may require you and your doctor to get prior approval from UPMC for Life. The document below will advise you of which drugs require prior authorization.
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Step therapy requirements
In some cases you may need to first try certain drugs to treat a medical problem before we will cover another drug. Select your plan below to see which drugs require step therapy.
In some cases you may need to first try certain drugs to treat a medical problem before we will cover another drug. The document below will advise you of which drugs require step therapy.
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Quantity Limits
For certain prescription drugs, our plan limits the amount of the drug that we will cover. Prescription drugs with quantity limits are listed in your plan’s comprehensive formulary (list of covered drugs). To see if any of your prescription drugs have a quantity limit, select your plan’s comprehensive formulary above and check for "QL" next to the drug name under Requirements/Limits.
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Part B Drugs and Supplies
The document below contains a list of select Part B drugs that UPMC for Life covers.
The document below contains a list of drugs that require Part B Step Therapy.
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Get help with medication costs
All UPMC for Life Complete Care members have a $0 copay for covered prescription drugs filled at a participating pharmacy. You can save money on medications no matter the level of Extra Help (Low Income Subsidy) you receive. This benefit applies to all phases of prescription drug coverage.
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.
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 1-877-486-2048.
- Social Security at 1-800-772-1213 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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Next Steps
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