Coming soon: Formulary updates effective Jan. 1, 2025

Jan. 2025Important Notices

Please review updated information for the prescription drugs covered under each plan.

UPMC Health Plan Commercial plans

View Advantage Choice formulary updates: upmchp.us/acformularychanges
View Your Choice formulary updates: upmchp.us/ycformularychanges
Policies can be found here: upmchealthplan.com/providers/medical/resources/manuals/policies-procedures.aspx

UPMC for Life Medicare and SNP plans

View UPMC for Life formulary updates:

UPMC for Life Complete Care (HMO D-SNP): upmchp.us/MCcompletecareRxformulary
UPMC for Life Advantage Rx (HMO, PPO): upmchp.us/MCadvantageRxRXformulary
UPMC for Life Premier Rx (HMO, PPO): upmchp.us/MCpremierRxformulary
Medicare Part D policies can be found here: upmchealthplan.com/medicare/learn/basics/medicare-prescription-coverage
Medicare Part B policies can be found here: upmchealthplan.com/providers/medical/resources/manuals/policies-procedures.aspx

IVIG/SCIG preferred products
Effective Jan. 1, 2025, certain intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) products that are preferred in 2024 will move to nonpreferred for all UPMC lines of business. All products currently require prior authorization in 2024, which will continue in 2025 regardless of status. However, members currently on nonpreferred products will not need updated authorizations when switching to preferred products in 2025. Please reference upmchp.us/PreferredImmuneGlobulins for preferred and nonpreferred products.

IV oncology prior authorization
Effective Jan. 1, 2025, select medically administered oncology products will require a prior authorization for all UPMC lines of business and drug formularies. The prior authorization applies only to new starts to therapy. The criteria for approval include that the requested drug is used for a medically accepted indication, prescribed by or in consultation with a specialist, and used for a dose and duration consistent with FDA-approved labeling or clinical literature. Please refer to products that will newly require prior authorization as of Jan. 1, 2025: upmchp.us/IVoncologyPA

Exception request options
Requests for exceptions can be submitted to Pharmacy Services by one of the following methods:

Online: Through SureScripts ePA or through the portal at upmchp.us/ProviderPharmacyPAForms

Recent Announcements

The importance of PRD forms for complex patients and staying updated on changes

Personal representative designation (PRD) forms are critical to the care process for patients and providers alike. Not only do PRDs support accurate, efficient, and compliant patient care—they also streamline administrative processes.

Aug. 2025Important Notices

Important announcement: UPMC Health Plan retires MP.PA.147

This communication is in regards to UPMC Health Plan Policy MP.PA.147 – Diagnostic and Surveillance Colonoscopy, 18 Years Old and Older. UPMC Health Plan previously communicated that the prior authorization requirement under this policy would be paused until Sept. 1, 2025. However, policy MP.PA.147 has been retired, and this policy will no longer be implemented or active.

Aug. 2025Important Notices

CMS expands Medicare Advantage RADV audits to all eligible plans

On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a substantial expansion of its Risk Adjustment Data Validation (RADV) audit program for Medicare Advantage plans.

Aug. 2025What's New