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 medications that are not on our formulary, or you may be taking a medication 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. Talk to your doctor to decide if you should switch to another medication that we cover or make a coverage request. During your first 90 days as a member of our plan, we may cover a limited amount of your current medication therapy. This gives you a chance to talk to your doctor and determine the right course of action for you.

For non-long-term care residents:

For any medication that you are currently taking that is not on our formulary or that requires additional authorization, we may cover multiple fills to provide at least 30 days of medication 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. You and your doctor may decide to select a formulary alternative or make a coverage request. We will not pay for this medication 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 of at least 31 days of medication. If you need a medication 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 medication (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 nonformulary 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:

• Visit the Social Security Administration at socialsecurity.gov/prescriptionhelp. You can also call 1-800-772-1213 Monday through Friday between 8 a.m. to 7 p.m. TTY users should call 1-800-325-0778.
• Call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
• Call your State Medical Assistance (Medicaid) Office.

How does UPMC for Life manage drug utilization?

One of UPMC for Life's goals in designing drug formularies and utilization programs is to promote the safe and effective use of medications. We have built safeguards into our pharmacy system that are designed to minimize the chance of a harmful drug interaction from occurring.

UPMC for Life has identified major drug interactions and sends a warning when a community pharmacist tries to fill a prescription for a medication that interacts with another medication the member is currently taking. This safeguard has been in place for some time. It is reviewed as new drugs come to market and when 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.