Formulary

The List of Covered Drugs (also known as the Drug List or Formulary) is a list of prescription drugs, over-the-counter (OTC) drugs, and non-drug products and items that are covered for members enrolled in Upper Peninsula Health Plan (UPHP) MI Coordinated Health (HMO D-SNP).

Generic drugs are made up of the same active ingredients as brand name drugs.  They usually cost less than the brand name drug and usually don’t have well-known names.  Generic drugs are approved by the Food and Drug Administration (FDA).  UPHP MI Coordinated Health covers both brand name drugs and generic drugs.

OTCs are drugs or non-drug products that can be purchased at a pharmacy or store by anyone, without needing a prescription from a provider. UPHP MI Coordinated Health covers some OTC drugs and non-drug products under your pharmacy benefit at no cost to you. However, you will need a prescription from your provider for us to cover most of these drugs and non-drug products for you.

These drugs are available at pharmacies within our network.  A pharmacy is in our network if we have an agreement with them to work with us and provide you services.  We refer to these pharmacies as “network pharmacies.” You can use our Provider and Pharmacy Search tool to find network pharmacies in our network nearest to you. 

Extra rules or restrictions apply to certain drugs on our Drug List (read the MI Coordinated Health Member Handbook for more information).

Extra rules and restrictions for certain drugs include:

• Being required to use the generic version of a drug instead of the brand name drug.
• Getting our approval in advance before we agree to cover the drug for you. This is sometimes called “prior authorization (PA).”
• Being required to try a different drug first before we agree to cover the drug you ask for. This is sometimes called “step therapy.”
• Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.

Our Medicare Formularies page provides more information about the MI Coordinated Health Pharmacy Benefit, including:

• List of Covered Drugs
• Coverage Decision (Prior Authorization) Criteria
• Step Therapy Criteria
• Out-of-Network Pharmacy Coverage
• Prior Authorization (Coverage Determination) and Formulary Exception Requests
• Appeals and Grievances
• Medicare Member Real Time Benefit Inquiry Tool
• Prescription Drug Transition Policy

Centers for Medicare and Medicaid Services (CMS) Best Available Evidence Policy