Your UPMC Health Plan pharmacy benefits
Quick, easy access to the prescriptions you need
Our pharmacy program offers a wide variety of high-quality, effective generic and brand-name drugs. Here’s how to get the most from your pharmacy benefits and make your prescription pick-ups hassle-free.
Be sure your medications are covered
Check our formulary. This is a list of medications covered by UPMC Health Plan.* Use our drug search tool for quick results.
How do drugs get on the formulary?
First, each drug must be approved by the U.S. Food and Drug Administration.
Then, the UPMC Health Plan Pharmacy and Therapeutics Committee determines which FDA-approved drugs to cover. They decide based on each drug’s:
- Safety
- Effectiveness
- Cost
*Some employers use a company other than UPMC Health Plan to administer their pharmacy benefits program. Check your Certificate of Coverage and other plan documents to make sure you have a pharmacy benefits program through UPMC Health Plan.
Have a personal review
Your new prescription coverage with UPMC Health Plan may be different from your previous coverage. A pharmacy staff member can let you know if:
- You need to try a similar medication before the one you are currently taking is approved.
- Your medication is not covered.
- There is a recommended generic form of your medication.
None of these issues may come up, but why wait until you’re in line at the pharmacy to find out?
Sign up for a personal review of your medications. We can alert you to any potential issues—and help you resolve them right away.
Find a pharmacy near you
Our broad pharmacy network of more than 30,000 retail chain and independent pharmacies includes CVS/pharmacy, Giant Eagle, Rite Aid, Target, Walmart, and Wegmans (Erie locations).
| Step 1: Find your type of health insurance in this column | Step 2: Select your specific pharmacy benefit program from this column |
|---|---|
| Employer-sponsored (for non-retirees): | |
| Medicare Advantage: | |
| Medicare Special Needs Plans: | |
| Medical Assistance: | |
| Children's Health Insurance Program: | |
| Individual and Family — Marketplace Affordable Care Act Plans: | Individual and Family — underwritten Individual Advantage Plans: |
|
Use our mail-order pharmacy
You can order refills of prescriptions that are already on file with Express Scripts Inc. (ESI) by calling the ESI 24/7 customer service center at 1-877-787-6279 (TTY: 1-800-899-2114) or by logging in to the UPMC Health Plan member site to request refills online.
Reimbursement for a pharmacy claim
When you receive your prescription, some pharmacies may ask you to pay the full price of the medication rather than your normal copayment. If this happens, you can submit a Direct Reimbursement Claim to UPMC Health Plan and ask to be reimbursed. If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment.
To find reimbursement forms, log in to the UPMC Health Plan member site.Find out if the drugs you are taking have a generic equivalent
Every year, generic drugs save people billions of dollars. By choosing a generic medication, you:
- Often save on your prescription copayment.
- Get the same quality and effectiveness as that of a brand-name drug.
- Help keep medical care more affordable for everyone.
Log in to the UPMC Health Plan member site, our 24/7 online resource, and start saving money today.
What are generic drugs?
Generic drugs are cost-effective alternatives that offer the same level of safety and quality as their brand-name equivalents. Generic drugs have the same active ingredients, but they cost significantly less.
The Food and Drug Administration (FDA) regulates generic drug manufacturers just as it regulates the makers of brand-name medications.
What is a therapeutic substitute?
If your provider prescribes a medication that is not covered by UPMC Health Plan’s formulary, the pharmacist filling the prescription will contact your provider to receive a verbal order for a different medication. The substitute medication also treats your condition. Pharmacists are not permitted to change a medication by member request. All medication changes must be made by the provider.
Use our special services if you need them
Specialty medications
These medications are for complex and chronic diseases. UPMC Health Plan uses Accredo, a division of Express Scripts Inc., and Chartwell, for our specialty pharmacy administration.
Specialty drugs may require:
- Close management by a physician.
- Frequent dosing adjustments.
- Intensive clinical monitoring.
- In-depth patient training.
- Special handling or administration.
For these reasons, it is recommended that specialty medications be filled through Accredo or Chartwell pharmacies.
Both Accredo and Chartwell can dispense medications to your physician’s office as well as your home. It depends on where your medication will be administered. Because specialty medications have unique characteristics, they are limited to a 30-day supply.
Personalized care
Traditional retail and mail-order pharmacies are not able to offer you the higher level of care that our specialty medication support services can provide, including therapy-specific programs, patient financial assistance, and compliance monitoring. UPMC Health Plan’s specialty medication program provides you with personalized, highly technical care to help you get the most from your treatments.
Find out if your plan offers specialty pharmacy service, including any copayments that may apply. Log in to the UPMC Health Plan member site to review your pharmacy plan documents.
Your doctor can order new prescriptions, and you can order refills for specialty or injectable medications by contacting one of the following specialty pharmacies:
| Accredo | 1-800-803-2523 TTY: 1-800-955-8770 |
Monday through Friday 8 a.m. to 9 p.m. and Saturday 9 a.m. to 1 p.m. |
|---|---|---|
| Chartwell | 1-800-366-6020 | Monday through Friday 8 a.m. to 5:30 p.m. |
Oral chemotherapy (cancer) medications* – Your Choice and Open Choice formularies
Special cost-share rules may apply to select oral chemotherapy (cancer) medications. For a list of applicable oral chemotherapy medications, please call your Health Care Concierge team at the number listed on your member ID card, or view the oral chemotherapy drug list (PDF).
*This benefit does not apply to all Commercial plans. Please see your pharmacy benefit rider for more details.