Upper Peninsula Health Plan (UPHP) has a List of Cover Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by our plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the UPHP Drug List.
UPHP covers both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the U.S. Food and Drug Administration to be as safe and effective as the brand-name drugs.
The UPHP Drug List may change throughout the year. Please see “Formulary Updates and Changes” below for further information or contact the plan for the most recent list of drugs.
View the comprehensive formulary, which is a complete list of covered drugs, for the appropriate calendar year below. You can also search for a specific drug by keying in the first few letters of the drug name:
- UPHP Advantage & UPHP Choice Formulary (List of Covered Drugs)
(Clicking on this link will take you away from UPHP’s website.)(Last updated 06/01/2019.)
Did you know that UPHP offers mail order pharmacy for certain kinds of drugs? Generally, drugs provided through mail order are those you take on a regular basis. Usually a mail order pharmacy order will get to you in no more than 14 days. The 14-day time frame starts when you place the order until you receive it at the specified address via free standard shipping. Sometimes, your mail order may be delayed. If your mail order is delayed, you may still obtain your medication from your local retail network pharmacy.
For refills, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.
Please make sure to let the pharmacy know the best ways to contact you, so the pharmacy can reach you to confirm your order before shipping. For assistance and additional information about mail orders, please call UPHP Customer Service at 1-877-349-9324 (TTY: 711) Monday through Friday from 8 a.m. to 9 p.m., with week hours Oct. 1 through March 31. The call is free.
UPHP has a transition policy to help you get your medications when you first become a member of our plan. We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
For more information, read the UPHP Prescription Drug Transition Policy for the applicable plan year below:
Certain drugs may need to get approval from UPHP before we will agree to cover the drug for a member. This is called “prior authorization.” Sometimes plan approval is required so that we can be sure the drug is covered by Medicare rules. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If the prior authorization does not get approved, the drug might not be covered by the health plan. Refer to the UPHP Evidence of Coverage for further information on prior authorizations, or call UPHP Customer Service at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern time, with weekend hours Oct. 1 through March 31. The call is free. For more information on prior authorization, view the documents below.
- Prior Authorization Criteria (Clicking on this link will take you away from UPHP’s website.)
Step therapy encourages you to try a safer or more effective drug before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, UPHP may require you to try Drug A first. If Drug A does not work for you, the health plan will then cover Drug B. This requirement to try a different drug first is called “step therapy.”
Refer to the UPHP Evidence of Coverage for further information on step therapy, or call Magellan Rx Customer Service at 1-844-827-0182 (TTY: 711), seven days per week, 24 hours per day. The call is free. For more information on step therapy, view the documents below.
- Step Therapy Criteria (Clicking on this link will take you away from UPHP’s website.)
Review the latest changes to UPHP’s formulary. (Clicking on this link will take you away from UPHP’s website.)
UPHP’s Medicare Advantage plans have quantity limits. This is when there is a limit on the amount that a drug is covered per prescription, or within a specific time frame.
- Quantity Limits (Clicking on this link will take you away from UPHP’s website.)
Emergent and urgently needed out-of-network care are covered. If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill the prescription. You can ask UPHP to reimburse you for our share of the cost.
Refer to the UPHP Evidence of Coverage for further information on out-of-network coverage and asking the health plan to reimburse you for their share of the cost, or call Magellan Rx’s Customer Service at 1-844-827-0182 (TTY: 711) 24 hours a day, seven days a week. The call is free.
If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception” by submitting a formulary exception form, called a Coverage Determination Request Form. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
Download and print both the Centers for Medicare and Medicaid Services (CMS) Coverage Determination Request Form and UPHP Medicare Part D Coverage Determination Requests Forms below.
The doctor’s office may submit either form via fax to Magellan Rx at 248-341-8133 or via mail to:
Magellan Rx Management
PO Box 2187
Maryland Heights, MO 63043
Read more about the Medicare Prescription Drug Coverage Determination and Exceptions process here.
- CMS Best Available Evidence Policy (Clicking on this link will take you away from UPHP’s website.)
Page Last Updated: 06/4/2019
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